Detoxification and Substance Abuse Treatment TIP 45 U.S.

Detoxification and
Substance Abuse Treatment
A Treatment
Improvement
Protocol
TIP
45
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov
DETOXIFICATION
Detoxification and
Substance Abuse
Treatment
Norman S. Miller, M.D., FASAM
Consensus Panel Chair
Steven S. Kipnis, M.D., FACP
Consensus Panel Co-Chair
A Treatment
Improvement
Protocol
TIP
45

Public Health Service
1 Choke Cherry Road
Rockville, MD 20857
Acknowledgments
Public Domain Notice
Numerous people contributed to the development of this TIP (see pp. ixxii and appendices
D and E). This publication was produced by
The CDM Group, Inc. (CDM) under the
Knowledge Application Program (KAP) contract numbers 270-99-7072 and 270-04-7049
with the Substance Abuse and Mental Health
Services Administration (SAMHSA), U.S.
Department of Health and Human Services
(DHHS). Andrea Kopstein, Ph.D., M.P.H.,
Karl D. White, Ed.D., and Christina Currier
served as the Center for Substance Abuse
Treatment (CSAT) Government Project
Officers. Rose M. Urban, M.S.W., J.D.,
LCSW, CCAC, CSAC, served as the KAP
Executive Project Co-Director. Elizabeth
Marsh Cupino served as CDM KAP Managing
Project Co-Director. Sheldon Weinberg,
Ph.D., served as KAP Senior
Researcher/Applied Psychologist. Other KAP
personnel included Raquel Witkin, M.S.,
Deputy Project Manager; Susan Kimner,
Editorial Director; Jonathan Max Gilbert.
M.A., Editor/Writer; Deborah Steinbach,
M.A., Editor/Writer; James M. Girsch, Ph.D.,
Editor/Writer; Michelle Myers, Quality
Assurance Editor; and Sonja Easley and
Elizabeth Plevyak, Editorial Assistants. In
addition, Sandra Clunies, M.S., ICADC,
served as Content Advisor. Jonathan Max
Gilbert, M.A. served as a writer. Special
thanks go to Suzanne Gelber, Ph.D., for her
contributions to chapter 6, and Joan
Dilonardo, Ph.D., for her input on the TIP.
All materials appearing in this volume except

those taken directly from copyrighted sources
are in the public domain and may be reproduced or copied without permission from
SAMHSA/CSAT or the authors. Do not reproduce or distribute this publication for a fee
without specific, written authorization from
SAMHSAs Office of Communications.
Disclaimer
The opinions expressed herein are the views of
the consensus panel members and do not necessarily reflect the official position of CSAT,
SAMHSA, or DHHS. No official support of or
endorsement by CSAT, SAMHSA, or DHHS
for these opinions or for particular instruments, software, or resources described in this
document are intended or should be inferred.
The guidelines in this document should not be
considered substitutes for individualized client
care and treatment decisions.
ii
Electronic Access and Copies

of Publication
Copies may be obtained free of charge from
SAMHSAs National Clearinghouse for Alcohol
and Drug Information (NCADI), (800) 7296686 or (301) 468-2600; TDD (for hearing
impaired), (800) 487-4889, or electronically
through the following Internet World Wide
Web site: www.ncadi.samhsa.gov.
Recommended Citation
Center for Substance Abuse Treatment.
Detoxification and Substance Abuse
Treatment. Treatment Improvement Protocol
(TIP) Series 45. DHHS Publication No.
(SMA) 06-4131. Rockville, MD: Substance
Abuse and Mental Health Services
Administration, 2006.
Originating Office
Practice Improvement Branch, Division of
Services Improvement, Center for Substance
Abuse Treatment, Substance Abuse and Mental
Health Services Administration, 1 Choke
Cherry Road, Rockville, MD 20857.
DHHS Publication No. (SMA) 06-4131
Printed 2006
Acknowledgments
Contents
What Is a TIP?........................................................................................................vii
Consensus Panel ......................................................................................................ix
KAP Expert Panel and Federal Government Participants ................................................xi
Foreword ..............................................................................................................xiii
Executive Summary .................................................................................................xv
Chapter 1Overview, Essential Concepts, and Definitions in Detoxification........................1
Purpose of the TIP .....................................................................................................1
Audience ..................................................................................................................2
Scope ......................................................................................................................2
History of Detoxification Services...................................................................................2
Definitions................................................................................................................3
Guiding Principles in Detoxification and Substance Abuse Treatment .....................................7
Challenges to Providing Effective Detoxification ................................................................8
Chapter 2Settings, Levels of Care, and Patient Placement ...........................................11
Role of Various Settings in the Delivery of Services ...........................................................11
Other Concerns Regarding Levels of Care and Placement ...................................................20
Chapter 3An Overview of Psychosocial and Biomedical Issues During Detoxification .......23
Evaluating and Addressing Psychosocial and Biomedical Issues ...........................................24
Strategies for Engaging and Retaining Patients in Detoxification ..........................................33
Referrals and Linkages ..............................................................................................38
Chapter 4Physical Detoxification Services for Withdrawal From Specific Substances .......47
Psychosocial and Biomedical Screening and Assessment .....................................................47
Alcohol Intoxication and Withdrawal.............................................................................52
Opioids ..................................................................................................................66
Benzodiazepines and Other Sedative-Hypnotics ...............................................................74
Stimulants...............................................................................................................76
Inhalants/Solvents.....................................................................................................82
Nicotine..................................................................................................................84
Marijuana and Other Drugs Containing THC ..................................................................95
Anabolic Steroids......................................................................................................96
Club Drugs..............................................................................................................97
Management of Polydrug Abuse: An Integrated Approach.................................................101
Alternative Approaches ............................................................................................103
Considerations for Specific Populations ........................................................................105
iii
Chapter 5Co-Occurring Medical and Psychiatric Conditions.......................................121

General Principles of Care for Patients With Co-Occurring Medical Conditions .....................122
Treatment of Co-Occurring Psychiatric Conditions..........................................................136
Standard of Care for Co-Occurring Psychiatric Conditions ...............................................138
Chapter 6Financing and Organizational Issues .........................................................145
Preparing and Developing a Program...........................................................................145
Working in Todays Managed Care Environment.............................................................157
Preparing for the Future...........................................................................................168
Appendix ABibliography ......................................................................................169
Appendix BCommon Drug Intoxication Signs and Withdrawal Symptoms .....................223
Appendix CScreening and Assessment Instruments ...................................................225
Section I: Screening and Assessment for Alcohol Abuse ....................................................225
Section II: Screening and Assessment for Alcohol and Other Drug Abuse ..............................228
Appendix DResource Panel..................................................................................231
Appendix EField Reviewers..................................................................................233
Index ..................................................................................................................237
CSAT TIPs and Publications....................................................................................243
Figures
Figure 1-1 DSM-IV-TR Definitions of Terms .....................................................................6
Figure 1-2 Guiding Principles Recognized by the Consensus Panel .........................................7
Figure 2-1 Issues To Consider in Determining Whether Inpatient or Outpatient
Detoxification Is Preferred .......................................................................................21
Figure 3-1 Initial Biomedical and Psychosocial Evaluation Domains......................................25
Figure 3-2 Symptoms and Signs of Conditions That Require Immediate Medical Attention..........26
Figure 3-3 Strategies for De-escalating Aggressive Behaviors ...............................................28
Figure 3-4 Questions To Guide Practitioners To Better Understand the Patients Cultural
Framework ...........................................................................................................32
Figure 3-5 The Transtheoretical Model (Stages of Change) ..................................................36
Figure 3-6 Clinicians Characteristics Most Important to the Therapeutic Alliance....................38
Figure 3-7 Recommended Areas for Assessment To Determine Appropriate
Rehabilitation Plans...............................................................................................40
Figure 3-8 Strategies To Promote Initiation of Treatment and Maintenance Activities ................42
Figure 4-1 Assessment Instruments for Dependence and Withdrawal From Alcohol and
Specific Illicit Drugs................................................................................................49
Figure 4-2 Symptoms of Alcohol Intoxication ...................................................................53
Figure 4-3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal ..61
Figure 4-4 Signs and Symptoms of Opioid Intoxication and Withdrawal .................................67
Figure 4-5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents ........................77
iv
Contents
Figure 4-6 Other Sedative-Hypnotics and Their Phenobarbital Withdrawal Equivalents ............78
Figure 4-7 Stimulant Withdrawal Symptoms....................................................................79
Figure 4-8 Commonly Abused Inhalants/Solvents..............................................................83
Figure 4-9 DSM-IV-TR on Nicotine Withdrawal ...............................................................86
Figure 4-10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence ......................87
Figure 4-11 The Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ) ........................88
Figure 4-12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With
Other Psychiatric Conditions ....................................................................................89
Figure 4-13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications ......90
Figure 4-14 The 5 As for Brief Intervention .................................................................91
Figure 4-15 Some Definitions Regarding Disabilities ........................................................111
Figure 4-16 Impairment and Disability Chart .................................................................112
Figure 4-17 Locating Expert Assistance.........................................................................114
Figure 6-1 Financial Arrangements for Providers............................................................162
Contents
What Is a TIP?
Treatment Improvement Protocols (TIPs), developed by the Center for
Substance Abuse Treatment (CSAT), part of the Substance Abuse and
Mental Health Services Administration (SAMHSA) within the U.S.
Department of Health and Human Services (DHHS), are best-practice
guidelines for the treatment of substance use disorders. CSAT draws on
the experience and knowledge of clinical, research, and administrative
experts to produce the TIPs, which are distributed to facilities and individuals across the country. The audience for the TIPs is expanding
beyond public and private treatment facilities to include practitioners in
mental health, criminal justice, primary care, and other healthcare and
social service settings.
CSATs Knowledge Application Program (KAP) Expert Panel, a distinguished group of experts on substance use disorders and professionals in
such related fields as primary care, mental health, and social services,
works with the State Alcohol and Drug Abuse Directors to generate topics
for the TIPs. Topics are based on the fields current needs for information
and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies
and national organizations to be members of a resource panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. Then recommendations are
communicated to a consensus panel composed of experts on the topic who
have been nominated by their peers. This consensus panel participates in
a series of discussions. The information and recommendations on which
they reach consensus form the foundation of the TIP. The members of
each consensus panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice
and child welfare agencies, and private practitioners. A panel chair (or
co-chairs) ensures that the guidelines mirror the results of the groups
collaboration.
vii
A large and diverse group of experts closely

reviews the draft document. Once the changes
recommended by these field reviewers have
been incorporated, the TIP is prepared for
publication, in print and online. The TIPs
can be accessed via the Internet at
www.kap.samhsa.gov. The online TIPs are
consistently updated and provide the field
with state-of-the-art information.
While each TIP strives to include an evidence
base for the practices it recommends, CSAT
recognizes that the field of substance abuse
treatment is evolving, and research frequently
lags behind the innovations pioneered in the
field. A major goal of each TIP is to convey
viii
front-line information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either panelists clinical experience or the literature. If
research supports a particular approach, citations are provided.
This TIP, Detoxification and Substance
Abuse Treatment, revises TIP 19,
Detoxification From Alcohol and Other
Drugs. The revised TIP provides the clinical
evidence-based guidelines, tools, and
resources necessary to help substance abuse
counselors and clinicians treat clients who are
dependent on substances of abuse.
What Is a TIP?
Consensus Panel
Chair
Norman S. Miller, M.D., FASAM
Professor and Director of Addiction Medicine
Department of Psychiatry
Michigan State University
East Lansing, Michigan
Co-Chair
Steven S. Kipnis, M.D., FACP
Medical Director
Russell E. Blaisdell Addiction Treatment
Center
New York State Office of Alcoholism and
Substance Abuse Services
Orangeburg, New York
Workgroup Managers and

Co-Managers
Anne M. Herron, M.S.
Director
Division of State and Community Assistance
Substance Abuse and Mental Health Services
Administration
Rockville, Maryland
Ronald J. Hunsicker, D.Min., FACATA
President/Chief Executive Officer
National Association of Addiction Treatment
Providers
Lancaster, Pennsylvania
Robert J. Malcolm, Jr., M.D.
Professor of Psychiatry, Family Medicine,
and Pediatrics
Associate Dean for Continuing Medical
Education
Center for Drug and Alcohol Programs
Institute of Psychiatry
Medical University of South Carolina
Charleston, South Carolina
Anthony Radcliffe, M.D., FASAM

Chief of Addiction Medicine
Kaiser Permanente
Southern California Permanente Medical
Group
Fontana, California
Carl Rollynn Sullivan, III, M.D.
Professor
Director of Addiction Program
Department of Behavioral Medicine and
Psychiatry
School of Medicine
West Virginia University
Morgantown, West Virginia
Nancy R. VanDeMark, M.S.W.
Director of Colorado Social Research
Associates
Arapahoe House, Inc.
Thornton, Colorado
Panelists
Louis E. Baxter, Sr., M.D., FASAM
Executive Director
Physicians Health Program
Medical Society of New Jersey
Lawrenceville, New Jersey
Kenneth O. Carter, M.D., M.P.H., Dipl.Ac.
Psychiatrist
Acupuncture Detoxification Specialist
Carolinas Medical Center
Charlotte, North Carolina
Jean Lau Chin, M.A., Ed.D., ABPP
President
CEO Services
Alameda, California
ix
Charles A. Dackis, M.D.

Assistant Professor
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Sylvia J. Dennison, M.D.
Chief/Medical Director
Division of Addiction Services
University of Illinois
Chicago, Illinois
Patricia L. Mabry, Ph.D.
Health Scientist Administrator/Behavioral
Scientist
Office of Behavioral and Social Sciences
Research
Office of the Director
National Institutes of Health
Bethesda, Maryland
Hendree E. Jones, M.A., Ph.D.

Assistant Professor
CAP Research Director
Department of Psychiatry and Behavioral
Sciences
Johns Hopkins University Center
Baltimore, Maryland
Frances J. Joy, R.N., CD, CASAC
Manager
Alcohol and Drug Abuse Unit
State of Missouri Department of Mental Health
Fulton State Hospital
Fulton, Missouri
Consensus Panel
KAP Expert Panel and Federal

Government Participants
Barry S. Brown, Ph.D.
Adjunct Professor
University of North Carolina at Wilmington
Carolina Beach, North Carolina
Jacqueline Butler, M.S.W., LISW, LPCC,
CCDC III, CJS
Professor of Clinical Psychiatry
College of Medicine
University of Cincinnati
Cincinnati, Ohio
Deion Cash
Executive Director
Community Treatment & Correction
Center, Inc.
Canton, Ohio
Debra A. Claymore, M.Ed.Adm.
Owner/Chief Executive Officer
WC Consulting, LLC
Loveland, Colorado
Michael Galer, D.B.A., M.B.A., M.F.A.

Independent Consultant
Westminster, Massachusetts
Renata J. Henry, M.Ed.
Director
Division of Substance Abuse and
Mental Health
Delaware Health and Social Services
New Castle, Delaware
Joel Hochberg, M.A.
President
Asher & Partners
Los Angeles, California
Jack Hollis, Ph.D.
Associate Director
Center for Health Research
Kaiser Permanente
Portland, Oregon
Carlo C. DiClemente, Ph.D.

Chair
Department of Psychology
University of Maryland Baltimore County
Baltimore, Maryland
Mary Beth Johnson, M.S.W.

Director
Addiction Technology Transfer Center
National Office
University of MissouriKansas City
Kansas City, Missouri
Catherine E. Dube, Ed.D.

Brown University
Providence, Rhode Island
Eduardo Lopez, B.S.

Executive Producer
EVS Communications
Washington, DC
Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief
Services Research Branch
National Institute on Drug Abuse
Bethesda, Maryland
Holly A. Massett, Ph.D.

Academy for Educational Development
Washington, DC
xi
Diane Miller
Chief
Scientific Communications Branch
National Institute on Alcohol Abuse
and Alcoholism
Kensington, Maryland
Harry B. Montoya, M.A.
President/Chief Executive Officer
Hands Across Cultures
Espanola, New Mexico
Richard K. Ries, M.D.
Director/Professor
Outpatient Mental Health Services
Dual Disorder Programs
Harborview Medical Center
Seattle, Washington
Gloria M. Rodriguez, D.S.W.
Research Scientist
Division of Addiction Services
New Jersey Department of Health
and Senior Services
Trenton, New Jersey
Everett Rogers, Ph.D.
Center for Communications Programs
Johns Hopkins University
Baltimore, Maryland
Jean R. Slutsky, P.A., M.S.P.H.
Senior Health Policy Analyst
Agency for Healthcare Research & Quality
Rockville, Maryland
xii
Nedra Klein Weinreich, M.S.

President
Weinreich Communications
Canoga Park, California
Clarissa Wittenberg
Director
Office of Communications and Public Liaison
National Institute of Mental Health
Kensington, Maryland
Consulting Members
Paul Purnell, M.A.
Social Solutions, L.L.C.
Potomac, Maryland
Scott Ratzan, M.D., M.P.A., M.A.
Academy for Educational Development
Washington, DC
Thomas W. Valente, Ph.D.
Director, Master of Public Health Program
Department of Preventive Medicine
School of Medicine
University of Southern California
Alhambra, California
Patricia A. Wright, Ed.D.
Baltimore, Maryland
Expert Panel
Foreword
The Treatment Improvement Protocol (TIP) series supports SAMHSAs
mission of building resilience and facilitating recovery for people with or
at risk for mental or substance use disorders by providing best-practices
guidance to clinicians, program administrators, and payors to improve the
quality and effectiveness of service delivery, and, thereby promote recovery. TIPs are the result of careful consideration of all relevant clinical and
health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches a consensus on best
practices. This panels work is then reviewed and critiqued by field
reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers
bring to this highly participatory process have helped to bridge the gap
between the promise of research and the needs of practicing clinicians and
administrators to serve, in the most scientifically sound and effective ways,
people who abuse substances. We are grateful to all who have joined with
us to contribute to advances in the substance abuse treatment field.
Charles G. Curie, M.A., A.C.S.W.
Administrator
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
xiii
Executive Summary
This Treatment Improvement Protocol (TIP) is a revision of TIP 19,
Detoxification From Alcohol and Other Drugs (Center for Substance
Abuse Treatment 1995d). It provides clinicians with updated information and expands on the issues commonly encountered in the delivery of
detoxification services. Like its predecessor, this TIP was created by a
panel of experts (the consensus panel) with diverse experience in detoxification servicesphysicians, psychologists, counselors, nurses, and
social workers, all with particular expertise to share.
This diverse group agreed to the following principles, which served as a
basis for the TIP:
1. Detoxification, in and of itself, does not constitute complete substance abuse treatment.
2. The detoxification process consists of three essential components,
which should be available to all people seeking treatment:
Evaluation
Stabilization
Fostering patient readiness for and entry into substance abuse
treatment
3. Detoxification can take place in a wide variety of settings and at a number of levels of intensity within these settings. Placement should be
appropriate to the patients needs.
4. All persons requiring treatment for substance use disorders should
receive treatment of the same quality and appropriate thoroughness
and should be put into contact with substance abuse treatment
providers after detoxification.
5. Ultimately, insurance coverage for the full range of detoxification services is cost-effective.
6. Patients seeking detoxification services have diverse cultural and ethnic
backgrounds as well as unique health needs and life situations.
Programs offering detoxification should be equipped to tailor treatment
to their client populations.
7. A successful detoxification process can be measured, in part, by
whether an individual who is substance dependent enters and
remains in some form of substance abuse treatment/rehabilitation
after detoxification.
Among the issues covered in this TIP is the importance of detoxification
as one component in the continuum of healthcare services for substance-related disorders. The TIP reinforces the urgent need for nonxv
traditional settingsemergency rooms, medical and surgical wards in hospitals, acute care
clinics, and othersto be prepared to participate in the process of getting the patient who
is in need of detoxification services into treatment as quickly as possible. Furthermore, it
promotes the latest strategies for retaining
individuals in detoxification while also
encouraging the development of the therapeutic alliance to promote the patients entrance
into substance abuse treatment. The TIP also
includes suggestions on addressing psychosocial issues that may impact detoxification
treatment, such as providing culturally
appropriate services to the patient population.
5. Level IV-D: Medically Managed Intensive

Inpatient Detoxification
Matching patients to appropriate care represents a challenge to detoxification programs.

Given the wide variety of settings and the
unique needs of the individual patient, establishing criteria that take into account all the
possible needs of patients receiving detoxification and treatment services is an extraordinarily complex task. Addiction medicine has
sought to develop an efficient system of care
that matches patients clinical needs with the
appropriate care setting in the least restrictive and most cost-effective manner. Patient
placement criteria, such as those published
by the American Society of Addiction
Medicine (ASAM) in the Patient Placement
Criteria, Second Edition, Revised, represent
an effort to define how care settings may be
matched to patient needs and special characteristics. These criteriathe five Adult
Detoxification placement levelsdefine the
most broadly accepted standard of care for
detoxification services. The five levels of care
are
Placement will depend in part on the substance of abuse. The consensus panel suggests
that for alcohol, sedative-hypnotic, and opioid withdrawal syndromes, hospitalization (or
some form of 24-hour medical care) is often
the preferred setting for detoxification, based
on principles of safety and humanitarian concerns. When hospitalization cannot be provided, then a setting that provides a high level
of nursing and medical backup 24 hours a
day, 7 days a week is desirable.
1. Level I-D: Ambulatory Detoxification

Without Extended Onsite Monitoring
2. Level II-D: Ambulatory Detoxification With
Extended Onsite Monitoring
3. Level II.2-D: Clinically Managed Residential
Detoxification
4. Level III.7-D: Medically Monitored
Inpatient Detoxification
xvi
ASAM criteria are being adopted extensively

on the basis of their face validity, though
their outcome validity has yet to be clinically
proven. The ASAM guidelines are to be
regarded as a work in progress, as their
authors readily admit. They are an important
set of guidelines that are of great help to clinicians. For administrators, the standards published by such groups as the Joint
Commission on Accreditation of Healthcare
Organizations and the Commission on
Accreditation of Rehabilitation Facilities provide guidance for overall program operations.
A further challenge for detoxification programs is to provide effective linkages to substance abuse treatment services. Patients
often leave detoxification without followup to
the treatment needed to achieve long-term
abstinence. Each year at least 300,000
patients with substance use disorders or acute
intoxication obtain inpatient detoxification in
general hospitals, while additional numbers
obtain detoxification in other settings. Only
20 percent of people discharged from acute
care hospitals receive substance abuse treatment during that hospitalization. Only 15
percent of people who are admitted to a
detoxification program through an emergency
room and then discharged go on to receive
treatment.
The consensus panel recognizes that medically assisted withdrawal is not always necessary
or desirable. A nonmedical approach can be
highly cost-effective and provide inexpensive
Executive Summary
access to treatment for individuals seeking

aid. Young individuals in good health, with no
history of previous withdrawal reactions, may
be well served by management of withdrawal
without medication. However, personnel
supervising in this setting should be trained to
identify life-threatening symptoms and solicit
help through the emergency medical system as
needed.
The consensus panel also agreed on several
guidelines for nonmedical detoxification programs. Such programs should follow local governmental regulations regarding their licensing
and inspection. In addition, it is desirable that
all such programs have an alcohol and drugfree environment as well as personnel who are
familiar with the features of substance use
withdrawal syndromes, have training in basic
life support, and have access to an emergency
medical system that can transport patients to
emergency departments and other sites for clinical care.
A major clinical question for detoxification is
the appropriateness of the use of medication
in the management of an individual in withdrawal. This can be a difficult matter because
protocols have not been firmly established
through scientific studies or evidence-based
methods. Furthermore, the course of withdrawal is unpredictable and currently available techniques of screening and assessment
do not predict who will experience life-threatening complications.
Although it is the philosophy of some treatment facilities to discontinue all medications,
this course of action is not always in the best
interest of the patient. Abrupt cessation of
psychotherapeutic medications may cause
severe withdrawal symptoms or the re-emergence of a psychiatric disorder. As a general
rule, therapeutic doses of medication should
be continued through any withdrawal if the
patient has been taking the medication as prescribed. Decisions about discontinuing the
medication should be deferred until after the
individual has completed detoxification. If,
however, the patient has been abusing the
Executive Summary
medication or the psychiatric condition was

clearly caused by substance use, then the
rationale for discontinuing the medication is
strengthened. Finally, practitioners should
consider withholding medication that lowers
the seizure threshold (e.g., bupropion, conventional antipsychotics) during the acute
alcohol withdrawal period or at least prescribing a loading dose or scheduled taper of
benzodiazepine.
Further studies are needed to confirm the
clinical experience that psychiatric symptoms
(including anxiety, depression, and personality disorders) respond to specific treatment of
the addiction. For example, cognitivebehavioral techniques employed in the 12-Step
treatment approach have been effective in the
management of anxiety and depression associated with addiction. Although challenging,
treatment of both addiction and co-occurring
psychiatric conditions has proven cost-effective in some studies.
This TIP also provides medical information
on detoxification protocols for specific substances as well as considerations for individuals with co-occurring medical conditions
including mental disorders. While the TIP is
not intended to take the place of medical
texts, it provides the practitioner with an
overview of common medical complications
seen in individuals who use substances.
Disorders of several systems are discussed in
some detail: gastrointestinal (including the
gastrointestinal tract, liver, and pancreas),
cardiovascular system, hematologic (blood)
abnormalities, pulmonary (lung) diseases, diseases of the central and peripheral nervous
system, infectious diseases, and special miscellaneous disorders. The TIP presents a cursory overview of special conditions, modifications in protocols, and the use of detoxification medications in patients with co-occurring
medical conditions or mental disorders.
Overall treatment of specific conditions is not
addressed unless modification of such treatment is needed.
xvii
The setting in which detoxification occurs is

also influenced by the existence of co-occurring medical disorders. It is highly desirable
that individuals undergoing detoxification be
assessed by primary care practitioners (i.e.,
physicians, physician assistants, nurse practitioners) with some experience in substance
abuse treatment. Such an assessment should
determine whether the patient is currently
intoxicated and the degree of intoxication; the
type and severity of the withdrawal syndrome; information regarding past withdrawals; and the presence of co-occurring
psychiatric, medical, and surgical conditions
that might require specialized care.
Particular attention should be paid to those
individuals who have undergone multiple
withdrawals in the past and for whom each
withdrawal appears worse than previous
ones. Subjects with a history of severe withdrawals, multiple withdrawals, delirium
tremens (a potentially fatal syndrome associated with alcohol withdrawal), or seizures are
not good candidates for detoxification programs in nonmedical settings.
The setting in which detoxification is carried
out should be appropriate for the medical
and psychological conditions present and
should be adequate to provide the degree of
monitoring needed to ensure safety (e.g.,
oximetry [a measurement of the amount of
oxygen present in the blood], greater frequency of taking vital signs, etc.). Acute, lifethreatening conditions need to be addressed
concurrently with the withdrawal process and
intensive care unit monitoring may be indicated. Detoxification staff providing support
should be familiar with the signs and symptoms of common co-occurring medical disorders. Likewise, personnel at medical facilities
(e.g., emergency rooms, physicians offices)
should be aware of the signs of withdrawal
and how it affects the treatment of the presenting medical conditions.
This TIP will also bring clinicians and administrators up to date on administrative issues
related to detoxification, including how the
services themselves can be paid for. It is
xviii
unusual in a clinical treatment improvement

protocol to discuss issues related to how clinical services are reimbursed. In the field of
substance abuse and detoxification services,
however, reimbursement issues have become
so intertwined with the delivery of services
that the consensus panel deemed it necessary
to address the conflicts and misunderstandings that sometimes arise between the care
systems and the reimbursement systems.
Third-party payors sometimes prefer to manage payment for detoxification separately
from other phases of substance abuse treatment, thus treating detoxification as if it
occurred in isolation from that treatment.
This unbundling of services can result in
the separation of services into scattered segments. In other instances, reimbursement and
utilization policies dictate that only detoxification can be authorized. This detoxification
often does not cover the nonmedical counseling that is an integral part of substance abuse
treatment.
Finally, identifying and maintaining funding
sources is a major issue in detoxification.
Substance abuse treatment in the United
States is financed through a diverse mix of
public and private sources, with substantially
more being spent by the public sector. The
existence of diverse funding streams in substance abuse treatment funding presents both
management challenges and opportunities for
program independence and stability.
However, a program with only one major
funding source is financially and clinically
vulnerable to changes in its major sources
budget and priorities. This situation should
be avoided. The TIP suggests ways to diversify funding sources to create a steady stream
of resources that can withstand the loss of one
particular funding source.
This TIP also makes recommendations for
fostering relationships with reimbursement
organizations, such as managed care organizations (MCOs). These positive working relationships are vital to successfully link the
patient to the needed services. For example,
Executive Summary
the MCO may use a wide variety of specific

criteria and protocols to determine whether
or not services may be authorized for substance abuse, typically including the ASAM
patient placement criteria and other level of
care or diagnosis-based criteria sets.
Successfully addressing the needs of the staff
at MCOs that are responsible for authorizing
the care provided to patients is a critical element in maintaining a relationship with an
MCO and the programs clinical and financial
viability. To do so, staff should understand
what MCO staff do, be well trained in conducting professional relationships over the
telephone, be familiar with the criteria and
protocols used by the MCOs with which the
program has contracts, and have easy access
to the abundance of clinical and service information required by an MCO in order to help
them complete a review and authorize services. Maintaining thorough, clear, and accurate records is essential to this process.
Detoxification staff also should be familiar
Executive Summary
with each MCOs appeal or exceptions process

for those occasions when the outcome of a
first-level review is unsatisfactory.
Regardless of their role in providing detoxification services, all personnel should keep in
mind that patients undergoing detoxification
are in the midst of a personal and medical
crisis. For many patients, this crisis represents a window of opportunity to acknowledge
their substance abuse problem and become
willing to seek treatment. Physicians, nurses,
substance abuse counselors, and administrators are in a unique position, not only to
ensure a safe and humane withdrawal from
substances of dependency, but also to foster
the path for the patients entry into substance
abuse treatment. This TIP suggests ways for
clinicians and programs to prepare the
patient for treatment while addressing the
complex psychosocial and medical variables
involved in detoxification.
xix
In This
Chapter
1 Overview, Essential
Concepts, and
Definitions in
Detoxification
Purpose of the TIP

Audience
Scope
History of Detoxification
Services
Definitions
Guiding Principles in
Detoxification and
Substance Abuse
Treatment
Challenges to Providing
Effective Detoxification
Chapter 1 provides a brief historical overview of changes in the perceptions and provision of detoxification services. It also introduces the core
concepts of the detoxification field, discusses the primary goals of detoxification services, clarifies the distinction between detoxification and treatment, and highlights some of the broader issues involved with providing
detoxification within systems of care.
Purpose of the TIP

This TIP is a revision of TIP 19, Detoxification From Alcohol and
Other Drugs (Center for Substance Abuse Treatment [CSAT] 1995d).
Significant changes in the area of detoxification services since the publication of TIP 19 include
Refinement of patient placement procedures
Increased knowledge of the physiology of withdrawal
Pharmacological advances in the management of withdrawal
Changes in the role of detoxification in the continuum of services for
patients with substance use disorders, and new issues in the management
of detoxification services within comprehensive systems of care
Emerging issues regarding specific populations (e.g., women, cultural
minorities, adolescents)
This TIP provides clinicians with up-to-date

information in these areas. It also expands on
the administrative, legal, and ethical issues
commonly encountered in the delivery of
detoxification services and suggests performance measures for detoxification programs.
Like its predecessor, this TIP was created by
a panel of experts with diverse experience in
detoxification servicesphysicians, psychologists, counselors, nurses, and social workers,
all with particular expertise to share.
Audience
The primary audiences for this TIP include
substance abuse treatment counselors; administrators of detoxification programs; Single State
Agency directors; psychiatrists and other
physicians working in the field; primary care
providers such as physicians, nurse practitioners, physician assistants, nurses, psychologists,
and other clinical staff members; staff of managed care and insurance carriers; policymakers; and others involved in planning, evaluating, and delivering services for detoxifying
patients from substances of abuse. Secondary
audiences include public safety/police and
criminal justice personnel, educational institutions, those involved with assisting workers
(e.g., Employee Assistance Programs), shelters/feeding programs, and managed care organizations. The TIP also should prove useful to
providers of other services in comprehensive
systems of care (vocational counseling, occupational therapy, and public housing/assisted living), administrators, and payors (public, private, and managed care).
Scope
Among other issues covered in this TIP is the
importance of detoxification as one component in the continuum of healthcare services
for substance-related disorders. The TIP
reinforces the urgent need for nontraditional
settingssuch as emergency rooms, medical
and surgical wards in hospitals, acute care
clinics, and others that do not traditionally
provide detoxification servicesto be prepared to participate in the process of getting

the patient who is in need of detoxification
into a program as quickly as possible to
potentially avoid the myriad possible negative
consequences associated with substance abuse
(e.g., physiological and psychological disturbances/disorders, criminal involvement,
unemployment, etc.). Furthermore, it promotes the latest strategies for retaining individuals in detoxification while also encouraging the development of the therapeutic
alliance to promote the patients entrance into
substance abuse treatment. This includes suggestions on addressing psychosocial issues
that may affect detoxification services.
This TIP provides medical information on
detoxification protocols for specific substances, as well as considerations for individuals with co-occurring medical conditions
including mental disorders. While the TIP is
not intended to take the place of medical
texts, it provides the practitioner with an
overview of medical considerations.
This TIP will also bring clinicians and administrators up-to-date on important aspects of
detoxification, including how the services are to
be paid for. It is unusual in a clinical treatment
improvement protocol to discuss issues related
to how clinical services are reimbursed.
However, in the field of substance abuse and
detoxification services, reimbursement issues
have become so intertwined with the delivery of
services that the consensus panel deemed it
necessary to address the conflicts and misunderstandings that sometimes arise between the
care systems and the reimbursement systems.
History of
Detoxification Services
Prior to the 1970s, public intoxication was
treated as a criminal offense. People arrested
for it were held in the drunk tanks of local
jails where they underwent withdrawal with
little or no medical intervention (Abbott et al.
Chapter 1
1995; Sadd and Young 1987). Shifts in the

medical field, in perceptions of addiction, and
in social policy changed the way that people
with dependency on drugs, including alcohol,
were viewed and treated. Two notable events
were particularly instrumental in changing
attitudes. In 1958, the American Medical
Association (AMA) took the official position
that alcoholism is a disease. This declaration
suggested that alcoholism was a medical problem requiring medical intervention. In 1971,
the National Conference of Commissioners on
Uniform State Laws adopted the Uniform
Alcoholism and Intoxication Treatment Act,
which recommended that alcoholics not be
subjected to criminal prosecution because of
their consumption of alcoholic beverages but
rather should be afforded a continuum of
treatment in order that they may lead normal
lives as productive members of society
(Keller and Rosenberg 1973, p. 2). While this
recommendation did not carry the weight of
law, it made a major change in the legal implications of addiction. With these changes came
more humane treatment of people with addictions.
Several methods of detoxification have evolved
that reflect a more humanitarian view of people
with substance use disorders. In the medical
model, detoxification is characterized by the
use of physician and nursing staff and the
administration of medication to assist people
through withdrawal safely (Sadd and Young
1987). The social model rejects the use of
medication and the need for routine medical
care, relying instead on a supportive nonhospital environment to ease the passage through
withdrawal (Sadd and Young 1987). Today, it is
rare to find a pure detoxification model. For
example, some social model programs use medication to ease withdrawal but generally employ
nonmedical staff to monitor withdrawal and
conduct triage (i.e., sorting patients according
to the severity of their disorders). Likewise,
medical programs generally have some components to address social/personal aspects of
addiction.
Just as the treatment and the conceptualization of addiction have changed, so too have
the patterns of substance use and the accompanying detoxification needs. The popularity
of cocaine, heroin, and other substances has
led to the need for different kinds of detoxification services. At
the same time, public
health officials have
The AMAs
increased investments in detoxificaposition is that subtion services and
substance abuse
treatment, especially
stance dependence
after 1985, as a
means to inhibit the
is a disease, and it
spread of HIV infection and AIDS
encourages physiamong people who
inject drugs. More
cians and other
recently, people with
substance use disorclinicians, health
ders are more likely
to abuse more than
organizations, and
one drug simultaneously (i.e., polydrug
policymakers to
abuse) (Office of
Applied Studies
2005).
base all their activiThe AMA continues
ties on this premise.
to maintain its position that substance
dependence is a disease, and it encourages physicians and other clinicians, health
organizations, and policymakers to base all
their activities on this premise (AMA 2002).
As treatment regimens have become more
sophisticated and polydrug abuse more common, detoxification has evolved into a compassionate science.
Definitions
Few clear definitions of detoxification and
related concepts are in general use at this
time. Criminal justice, health care, substance
abuse, mental health, and many other sys-
Overview, Essential Concepts, and Definitions in Detoxification
tems all define detoxification differently. This

TIP offers a clear and uniform set of definitions for the various components of detoxification and substance abuse treatment that
may prove useful to the field of detoxification.
Detoxification
Detoxification is a set of interventions aimed
at managing acute intoxication and withdrawal. It denotes a clearing of toxins from the
body of the patient who is acutely intoxicated
and/or dependent on substances of abuse.
Detoxification seeks to minimize the physical
harm caused by the abuse of substances. The
acute medical management of life-threatening
intoxication and related medical problems
generally is not included within the term
detoxification and is not covered in detail in
this TIP.
The Washington Circle Group (WCG), a body
of experts organized to improve the quality
and effectiveness of substance abuse prevention and treatment, defines detoxification as
a medical intervention that manages an individual safely through the process of acute
withdrawal (McCorry et al. 2000a, p. 9).
The WCG makes an important distinction,
however, in noting that a detoxification program is not designed to resolve the longstanding psychological, social, and behavioral
problems associated with alcohol and drug
abuse (McCorry et al. 2000a, p. 9). The consensus panel supports this statement and has
taken special care to note that detoxification

is not substance abuse treatment and rehabilitation. For further explanation, see the text
box below.
The consensus panel built on existing definitions of detoxification as a broad process with
three essential components that may take
place concurrently or as a series of steps:
Evaluation entails testing for the presence
of substances of abuse in the bloodstream,
measuring their concentration, and screening for co-occurring mental and physical
conditions. Evaluation also includes a comprehensive assessment of the patients medical and psychological conditions and social
situation to help determine the appropriate
level of treatment following detoxification.
Essentially, the evaluation serves as the
basis for the initial substance abuse treatment plan once the patient has been withdrawn successfully.
Stabilization includes the medical and psychosocial processes of assisting the patient
through acute intoxication and withdrawal
to the attainment of a medically stable, fully
supported, substance-free state. This often
is done with the assistance of medications,
though in some approaches to detoxification
no medication is used. Stabilization
includes familiarizing patients with what to
expect in the treatment milieu and their
role in treatment and recovery. During this
time practitioners also seek the involvement
of the patients family, employers, and
Detoxification as Distinct From Substance

Abuse Treatment
Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. Supervised
detoxification may prevent potentially life-threatening complications that might appear if the patient
were left untreated. At the same time, detoxification is a form of palliative care (reducing the intensity of
a disorder) for those who want to become abstinent or who must observe mandatory abstinence as a
result of hospitalization or legal involvement. Finally, for some patients it represents a point of first contact with the treatment system and the first step to recovery. Treatment/rehabilitation, on the other
hand, involves a constellation of ongoing therapeutic services ultimately intended to promote recovery
for substance abuse patients.
4
Chapter 1
other significant people when appropriate

and with release of confidentiality.
Fostering the patients entry into treatment
involves preparing the patient for entry into
substance abuse treatment by stressing the
importance of following through with the
complete substance abuse treatment continuum of care. For patients who have demonstrated a pattern of completing detoxification services and then failing to engage in
substance abuse treatment, a written treatment contract may encourage entrance into
a continuum of substance abuse treatment
and care. This contract, which is not legally
binding, is voluntarily signed by patients
when they are stable enough to do so at the
beginning of treatment. In it, the patient
agrees to participate in a continuing care
plan, with details and contacts established
prior to the completion of detoxification.
All three components (evaluation, stabilization, and fostering a patients entry into
treatment) involve treating the patient with
compassion and understanding. Patients
undergoing detoxification need to know that
someone cares about them, respects them as
individuals, and has hope for their future.
Actions taken during detoxification will
demonstrate to the patient that the providers
recommendations can be trusted and followed.
Other Relevant Terms

As defined by the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition,
Text Revision (DSM-IV-TR) (American
Psychiatric Association [APA] 2000), a substance-related disorder is a disorder related
to the taking of a drug of abuse (including
alcohol), to the side effects of a medication,
and to toxin exposure (APA 2000, p. 191).
The term substance can refer to a drug of
abuse, a medication, or a toxin (APA 2000,
p. 191). In this TIP, the term substance refers
to alcohol as well as other drugs of abuse.
Substance-related disorders are divided into
two groups: substance use disorders and sub-
stance-induced disorders. According to the

DSM-IV-TR, substance use disorders include
both substance dependence and substance
abuse. Substance dependence refers to a
cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is
a pattern of repeated self-administration that
can result in tolerance, withdrawal, and compulsive drug-taking behavior (APA 2000, p.
192). Substance abuse refers to a maladaptive pattern of substance use manifested by
recurrent and significant adverse consequences related to the repeated use of substances (APA 2000, p. 198). It should be
noted that for purposes of this TIP, the term
substance abuse is sometimes used to
denote both substance abuse and substance
dependence as they are defined by the DSMIV-TR.
This TIP also uses the DSM-IV-TR definitions
for substance intoxication and substance
withdrawal. Substance intoxication is the
development of a reversible substance-specific
syndrome due to the recent ingestion of (or
exposure to) a substance whereas substance
withdrawal is the development of a substance-specific maladaptive behavioral
change, with physiological and cognitive concomitants, that is due to the cessation of, or
reduction in, heavy and prolonged substance
use (APA 2000, pp. 199, 201). Figure 1-1
(p. 6) defines these and other relevant terms.
Treatment/rehabilitation includes an ongoing,

continual assessment of the patients physical,
psychological, and social status, as well as an
analysis of environmental risk factors that
may be contributing to substance use and the
identification of immediate relapse triggers as
well as prevention strategies for coping with
them. It also includes the delivery of primary
medical care and psychiatric care, if necessary, to help the patient abstain from substance use and minimize the physical harm
caused by it. Ultimately, the goal of treatment/rehabilitation is to attain a higher level
of social functioning by reducing risk factors,
Figure 1-1
DSM-IV-TR Definitions of Terms
Term
Definition
Substance
A drug of abuse, a medication, or a toxin.
Substance-related disorders
Disorders related to the taking of a drug of abuse (including

alcohol), to the side effects of a medication, and to toxin exposure.
Substance abuse (in this TIP, also

sometimes used to denote substance
dependence)
A maladaptive (i.e., harmful to a persons life) pattern of substance use marked by recurrent and significant negative consequences related to the repeated use of substances.
Substance dependence (in this TIP,

substance abuse is sometimes used
to include dependence)
A cluster of cognitive, behavioral, and physiological symptoms

indicating that the individual is continuing use of the substance
despite significant substance-related problems. A person experiencing substance dependence shows a pattern of repeated selfadministration that usually results in tolerance, withdrawal, and
compulsive drug-taking behavior.
Substance intoxication
The development of a reversible substance-specific syndrome as

the result of the recent ingestion of (or exposure to) a substance.
Substance withdrawal
The development of a substance-specific maladaptive behavioral

change, usually with uncomfortable physiological and cognitive
consequences, that is the result of a cessation of, or reduction in,
heavy and prolonged substance use.
Source: APA 2000.

enhancing protective factors, and thus
decreasing the possibility of relapse.
Maintenance includes the continuation of

counseling and support specified in the treatment plan, refinement and strengthening of
strategies to avoid relapse, and engagement in
ongoing relapse prevention, aftercare, and/or
domiciliary care (Lehman et al. 2000).
patients to emphasize that these persons are

coming into contact with physicians, nurses,
physician assistants, and medical social workers in a medical setting in which the patient
often is physically ill from the effects of withdrawal from specific substances. In some
social setting detoxification programs, the
terms client or consumer may be used in
place of patient.
As a final note, in this TIP persons in need of

detoxification services and subsequent substance abuse treatment are referred to as
6
Chapter 1
Guiding Principles in
Detoxification and
Substance Abuse
Treatment
empirically measurable and agreed upon by all

parties. The consensus panel developed guidelines (listed in Figure 1-2) that serve as the
foundation for the TIP.
The consensus panel recognizes that the successful delivery of detoxification services is
dependent on standards that are to some extent
Figure 1-2
Guiding Principles Recognized by the Consensus Panel
1. Detoxification does not constitute substance abuse treatment but is one part of a continuum of care for
substance-related disorders.
2. The detoxification process consists of the following three sequential and essential components:
Evaluation
Stabilization
Fostering patient readiness for and entry into treatment
A detoxification process that does not incorporate all three critical components is considered incomplete
and inadequate by the consensus panel.
3. Detoxification can take place in a wide variety of settings and at a number of levels of intensity within
these settings. Placement should be appropriate to the patients needs.
4. Persons seeking detoxification should have access to the components of the detoxification process
described above, no matter what the setting or the level of treatment intensity.
5. All persons requiring treatment for substance use disorders should receive treatment of the same
quality and appropriate thoroughness and should be put into contact with a substance abuse treatment program after detoxification, if they are not going to be engaged in a treatment service provided
by the same program that provided them with detoxification services. There can be no wrong door
to treatment for substance use disorders (CSAT 2000a).
6. Ultimately, insurance coverage for the full range of detoxification services is cost-effective. If reimbursement systems do not provide payment for the complete detoxification process, patients may be
released prematurely, leading to medically or socially unattended withdrawal. Ensuing medical complications ultimately drive up the overall cost of health care.
7. Patients seeking detoxification services have diverse cultural and ethnic backgrounds as well as
unique health needs and life situations. Organizations that provide detoxification services need to
ensure that they have standard practices in place to address cultural diversity. It also is essential that
care providers possess the special clinical skills necessary to provide culturally competent comprehensive assessments. Detoxification program administrators have a duty to ensure that appropriate
training is available to staff. (For more information on cultural competency training and specific
competencies that clinicians need to be culturally competent see the forthcoming TIP Improving
Cultural Competence in Substance Abuse Treatment [CSAT in development a]).
8. A successful detoxification process can be measured, in part, by whether an individual who is substance dependent enters, remains in, and is compliant with the treatment protocol of a substance
abuse treatment/rehabilitation program after detoxification.
Challenges to
Providing Effective
Detoxification
It is an important challenge for detoxification
service providers to find the most effective
way to foster a patients recovery. Effective
detoxification includes not only the medical
stabilization of the patient and the safe and
humane withdrawal from drugs, including
alcohol, but also entry into treatment.
Successfully linking detoxification with substance abuse treatment reduces the revolving
door phenomenon of repeated withdrawals,
saves money in the medium and long run, and
delivers the sound and humane level of care
patients need (Kertesz et al. 2003). Studies
show that detoxification and its linkage to the
appropriate levels of treatment lead to
increased recovery and decreased use of
detoxification and treatment services in the
future. In addition, recovery leads to reductions in crime, general healthcare costs, and
expensive acute medical and surgical treatments consequent to untreated substance
abuse (Abbot et al. 1998; Aszalos et al. 1999).
While detoxification is not treatment per se,
its effectiveness can be measured, in part, by
the patients continued abstinence.
Another challenge to providing effective
detoxification occurs when programs try to
develop linkages to treatment services. A
study (Mark et al. 2002) conducted for the
Administration highlights the pitfalls of the
service delivery system. According to the
authors, each year at least 300,000 patients
with substance use disorders or acute intoxication obtain inpatient detoxification in general hospitals while additional numbers
obtain detoxification in other settings. Only
about one-fifth of people discharged from
acute care hospitals for detoxification receive
substance abuse treatment during that hospitalization. Moreover, only 15 percent of people who are admitted through an emergency
room for detoxification and then discharged
receive any substance abuse treatment.
8
Finally the average length of stay for people

undergoing detoxification and treatment in
1997 was only 7.7 days (Mark et al. 2002).
Given that research has shown that patients
who receive continuing care have better outcomes in terms of drug abstinence and readmission rates than those who do not receive
continuing care, the report authors conclude
that there is a pronounced need for better
linkage between detoxification services and
the treatment services that are essential for
full recovery (Mark et al. 2002, p. 3).
Reimbursement systems can present another
challenge to providing effective detoxification
services (Galanter et al. 2000). Third-party
payors sometimes prefer to manage payment
for detoxification separately from other phases of addiction treatment, thus treating detoxification as if it occurred in isolation from
addiction treatment. This unbundling of
services has promoted the separation of all
services into somewhat scattered segments
(Kasser et al. 2000). In other instances, some
reimbursement and utilization policies dictate
that only detoxification currently can be
authorized, and detoxification for that policy or insurer does not cover the nonmedical
counseling that is an integral part of substance abuse treatment. Many treatment programs have found substance abuse counselors
to be of special help with resistant patients,
especially for patients with severe underlying
shame over the fact that their substance use is
out of control. Yet some payors will not reimburse for nonmedical services such as those
provided by these counselors, and therefore
the use of such staff by a detoxification or
treatment service may be impossible, in spite
of the fact that they are widely perceived as
useful for patients.
Payors are gradually beginning to understand
that detoxification is only one component of a
comprehensive treatment strategy. Patient
placement criteria, such as those published
by the American Society of Addiction
Medicine (ASAM) in the Patient Placement
Criteria, Second Edition, Revised (ASAM
2001), have come to the fore as clinicians and
Chapter 1
insurers try to reach agreements on the level

of treatment required by a given patient, as
well as the medically appropriate setting in
which the treatment services are to be delivered. Accordingly, the TIP offers suggestions
for resolving conflicts as well as clearly defining terms used in patient placement and treatment settings as a step toward clearer understanding among interested parties.
2 Settings, Levels of
Care, and Patient
Placement
In This
Chapter
Role of Various
Settings in the
Delivery of Services
Other Concerns
Regarding Levels of
Care and Placement
Establishing criteria that take into account all the possible needs of
patients receiving detoxification and treatment services is an extraordinarily complex task. This chapter discusses the criteria for placing
patients in the appropriate treatment settings and offering the required
intensity of services (i.e., level of care).
Role of Various Settings in the

Delivery of Services
Addiction medicine has sought to develop an efficient system of care that
matches patients clinical needs with the appropriate care setting in the
least restrictive and most cost-effective manner. (For an explanation of
least restrictive care, see the text box, p. 12.) Challenges to effective
placement matching for clients arise from a number of factors:
Deficits in the full range of care settings and levels of care
Limitations imposed by third-party payors (e.g., strict adherence to
standardized admission criteria)
Clinicians lack of authority (and sometimes sufficient knowledge) to
determine the most appropriate care setting and level of care
Insurance that does not have a substance use disorder benefit available
as part of its patient coverage
Absence of any health insurance at all (Gastfriend et al. 2000)
No clear solution or formula to meet these challenges has emerged.
11
Least Restrictive Care

Least restrictive refers to patients civil rights and their right to choice of care. There are four specific themes of historical and clinical importance:
1. Patients should be treated in those settings that least interfere with their civil rights and freedom to
participate in society.
2. Patients should be able to disagree with clinician recommendations for care. While this includes the
right to refuse any care at all, it also includes the right to obtain care in a setting of their choice (as
long as considerations of dangerousness and mental competency are satisfied). It implies a patients
right to seek a higher or different level of care than that which the clinician has planned.
3. Patients should be informed participants in defining their care plan. Such planning should be done
in collaboration with their healthcare providers.
4. Careful consideration of State laws and agency policies is required for patients who are unable to
act in their own self-interests. Because the legal complexities of this issue will vary from State to
State the TIP cannot provide definitive guidance here, but providers need to consider whether or
not the person is gravely incapacitated, suicidal, or homicidal; likely to commit grave bodily
injury; or, in some States, likely to cause injury to property. In such cases, State law and/or case
law may hold providers responsible if they do not commit the patient to care, but in other cases
programs may be open to lawsuits for forcibly holding a patient.
In spite of the impediments, some progress has
been made in developing comprehensive
patient placement criteria. Because the choice
of a treatment setting and intensity of treatment (level of care) are so important, the
American Society of Addiction Medicine
(ASAM) created the Patient Placement
Criteria, Second Edition, Revised (PPC-2R) a
consensus-based clinical tool for matching
patients to the appropriate setting and level of
care. The ASAM PPC-2R represents an effort
to define how care settings may be matched to
patient needs and special characteristics. These
criteria currently define the most broadly
accepted standard of care for the treatment of
substance use disorders. ASAM criteria are
intended to provide flexible clinical guidelines;
these criteria may not be appropriate for particular patients or specific care settings.
The PPC-2R identifies six assessment dimensions to be evaluated in making placement
decisions (ASAM 2001, p. 4). They are as
follows:
1. Acute Intoxication and/or Withdrawal
Potential
12
2. Biomedical Conditions and Complications

3. Emotional, Behavioral, or Cognitive
Conditions and Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued
Problem Potential
6. Recovery/Living Environment
The ASAM PPC-2R describes both the settings
in which services may take place and the intensity of services (i.e., level of care) that patients
may receive in particular settings. It is important to reiterate, however, that the ASAM
PPC-2R criteria do not characterize all the
details that may be essential to the success of
treatment (Gastfriend et al. 2000). Moreover,
traditional assumptions that certain treatment
can be delivered only in a particular setting
may not be applicable or valuable to patients.
Clinical judgment and consideration of the
patients particular situation are required for
appropriate detoxification and treatment.
In addition to the general placement criteria
for treatment for substance-related disorders,
ASAM also has developed a second set of placeChapter 2
ment criteria, which are more important for

the purposes of this TIPthe five Adult
Detoxification placement levels of care within
Dimension 1 (ASAM 2001). These Adult
Detoxification levels of care are
1. Level I-D: Ambulatory Detoxification
Without Extended Onsite Monitoring (e.g.,
physicians office, home health care agency). This level of care is an organized outpatient service monitored at predetermined intervals.
2. Level II-D: Ambulatory Detoxification
With Extended Onsite Monitoring (e.g.,
day hospital service). This level of care is
monitored by appropriately credentialed
and licensed nurses.
3. Level III.2-D: Clinically Managed
Residential Detoxification (e.g., nonmedical or social detoxification setting). This
level emphasizes peer and social support
and is intended for patients whose intoxication and/or withdrawal is sufficient to
warrant 24-hour support.
4. Level III.7-D: Medically Monitored
Inpatient Detoxification (e.g., freestanding
detoxification center). Unlike Level
III.2.D, this level provides 24-hour medically supervised detoxification services.
5. Level IV-D: Medically Managed Intensive
Inpatient Detoxification (e.g., psychiatric
hospital inpatient center). This level provides 24-hour care in an acute care inpatient settings.
As described by the ASAM PPC-2R, the
domain of detoxification refers not only to the
reduction of the physiological and psychological features of withdrawal syndromes, but
also to the process of interrupting the momentum of compulsive use in persons diagnosed
with substance dependence (ASAM 2001).
Because of the force of this momentum and
the inherent difficulties in overcoming it even
when there is no clear withdrawal syndrome,
this phase of treatment frequently requires a
greater intensity of services initially to establish participation in treatment activities and
patient role induction. That is, this phase
Settings, Levels of Care, and Patient Placement
should increase the patients readiness for

and commitment to substance abuse treatment and foster a solid therapeutic alliance
between the patient and care provider.
It is important to note that ASAM PPC-2R
criteria are only guidelines, and that there
are no uniform protocols for determining
which patients are placed in which level of
care. For further information on patient
placement, readers are advised to consult
TIP 13, The Role and Current Status of
Patient Placement Criteria in the Treatment
of Substance Use Disorders (Center for
Substance Abuse Treatment [CSAT] 1995h).
Because this TIP is geared to audiences that
may or may not be familiar with the ASAM
PPC-2R levels of care, this section discusses
the services and staffing specific to the care
settings that are familiar to a broad audience.
Physicians Office
It has been estimated that nearly one half of
the patients who visit a primary care provider
have some type of problem related to substance use (Miller and Gold 1998). Indeed,
because the physician may be the first point
of contact for these people, initiation of treatment often begins in the family physicians
office (Prater et al. 1999). Physicians should
use prudence in determining which patients
may undergo detoxification safely on an outpatient basis. As a general rule, outpatient
treatment is just as effective as inpatient
treatment for patients with mild to moderate
withdrawal symptoms (Hayashida 1998).
For physicians treating patients with substance use disorders, preparing the patient to
enter treatment and developing a therapeutic
alliance between patient and clinician should
begin as soon as possible. This includes providing the patient and his family with information on the detoxification process and subsequent substance abuse treatment, in addition to providing medical care or referrals if
necessary. Staffing should include certified
interpreters for the deaf and other language
13
interpreters if the program is serving patients

in need of those services. Physicians should
be able to accommodate frequent followup
visits during the management of acute withdrawal. Medications should be dispensed in
limited amounts.
Level of care
Ambulatory detoxification without
extended onsite monitoring
Staffing
This level of detoxification (ASAMs Level ID) is an organized outpatient service, which
may be delivered in an office setting, healthcare or addiction treatment facility, or in a
patients home by trained clinicians who provide medically supervised evaluation, detoxification, and referral services according to a
predetermined schedule. Such services are
provided in regularly scheduled sessions.
These services should be delivered under a
defined set of policies and procedures or medical protocols (ASAM 2001). Ambulatory
detoxification is considered appropriate only
when a positive and helpful social support
network is available to the patient. In this
level of care, outpatient detoxification services should be designed to treat the patients
level of clinical severity, to achieve safe and
comfortable withdrawal from mood-altering
drugs, and to effectively facilitate the
patients transition into treatment and recovery.
Although they need not be present in the

treatment setting at all times, physicians and
nurses are essential to office-based detoxification. In States where physician assistants,
nurse practitioners, or advance practice clinical nurse specialists are licensed as physician
extenders, they may perform the duties ordinarily carried out by a physician (ASAM
2001).
Ambulatory detoxification with

extended onsite monitoring
Understanding how to interpret the signs and

symptoms of alcohol and other drug intoxication and withdrawal
Essential to this level of careand distinguishing it from Ambulatory Detoxification

Without Extended Onsite Monitoringis the
availability of appropriately credentialed and
licensed nurses (such as registered nurses
[RNs] or licensed practical nurses [LPNs])
who monitor patients over a period of several
hours each day of service (ASAM 2001).
Otherwise, this level of detoxification
(ASAMs Level II-D) also is an organized outpatient service. Like Level I-D, in this level of
care detoxification services are provided in
regularly scheduled sessions and delivered
14
under a defined set of policies and procedures

or medical protocols. Outpatient services are
designed to treat the patients level of clinical
severity and to achieve safe and comfortable
withdrawal from mood-altering drugs, including alcohol, and to effectively facilitate the
patients entry into ongoing treatment and
recovery (ASAM 2001).
Because detoxification is conducted on an

outpatient basis in these settings, it is important for medical and nursing personnel to be
readily available to evaluate and confirm that
detoxification in the less supervised setting is
safe. All clinicians who assess and treat
patients should be able to obtain and interpret information regarding the needs of these
persons, and all should be knowledgeable
about the biomedical and psychosocial dimensions of alcohol and illicit drug dependence.
Requisite skills and knowledge base include
the following:
Understanding the appropriate treatment

and monitoring of these conditions
The ability to facilitate the individuals entry
into treatment
It is essential that medical consultation is
readily available in emergencies. It is desirable that medical staff link patients to treatment services, although this may be an unreasonable expectation that cannot be met in a
busy office setting. Linkage to treatment services may be provided by the physician or by
Chapter 2
designated counselors, psychologists, social

workers, and acupuncturists who are available either onsite or through the healthcare
system (ASAM 2001).
Freestanding Urgent Care

Center or Emergency
Department
There are several distinctions between urgent
care facilities and emergency rooms (ERs).
Urgent care often is used by patients who
cannot or do not want to wait until they see
their doctor in his or her office, whereas
emergency rooms are utilized more often by
patients who perceive themselves to be in a
crisis situation. Unlike emergency departments, which are required to operate 24
hours a day, freestanding urgent care centers
usually have specific hours of operation.
Staffing for urgent care centers generally is
more limited than for an ER. Standard
staffing includes only a physician, an RN, a
technician, and a secretary. Despite these distinctions, in actual practice there is considerable overlap between the twothe ER will see
medical problems that could be handled by
visits to offices, and urgent care facilities will
handle some cases of emergency medicine.
A freestanding urgent care center or emergency department reasonably can be expected to
provide assessment and acute biomedical
(including psychiatric) care. However, these
settings often are unable to provide satisfactory psychosocial stabilization or complete
biomedical stabilization (which includes both
the initiation and taper of medications used in
the treatment of substance withdrawal syndromes). Appropriate triage and successful
linkage to ongoing detoxification services is
essential. The ongoing detoxification services
may be provided in an inpatient, residential,
or outpatient setting. Patients with more than
moderate biomedical or psychosocial complications are more likely to require treatment
in an inpatient setting. Care in these settings
can be quite costly and should be accessed
only when there are serious concerns about a

patients safety.
A timely and accurate assessment in an emergency department is of the highest importance. This will permit the rapid transfer of
the patient to a setting where complete care
can be provided.
Ideally, personnel in
the emergency
Although they
department will have
at least a small
need not be
amount of experience and expertise in
present in the
identifying critically
ill substance-using
treatment setting
patients who may be
about to experience
at all times,
or are already experiencing withdrawal
symptoms. Three
physicians and
essential rules apply
to emergency departnurses are
ments and their handling of intoxicated
essential to
patients and patients
who have begun to
office-based
experience withdrawal:
detoxification.
Emergency departments and their

clinicians should
never simply
administer medications to intoxicated persons
and then send them home.
No intoxicated patient should ever be allowed
to leave a hospital setting. All such persons
should be referred to the appropriate detoxification setting if possible, although there are
legal restrictions that forbid holding persons
against their will under certain conditions
(Armenian et al. 1999).
A clear distinction must be made between
acute intoxication on the one hand and withdrawal on the other. Acute intoxication, it
must be remembered, creates special issues
and challenges that need to be addressed.
The risk of suicidality in patients who present in a state of intoxication needs to be
15
carefully assessed. Because of their volatility

and often risky behavior, patients who are
intoxicated, as well as those patients who
have begun to experience withdrawal, merit
special attention. For more on treating intoxicated patients, see chapter 3.
Level of care
Care is provided to
patients whose withdrawal signs and
detoxification
symptoms are sufficiently severe to
require primary
provides 24-hour
medical and nursing
care services. The
supervision,
services are delivered under a
observation, and
defined set of physician-managed prosupport for
cedures or medical
protocols. Both setpatients who are
tings provide medically directed assessintoxicated or
ment and acute care
that includes the iniexperiencing
tiation of detoxification for substance
use withdrawal.
withdrawal.
Neither setting is
likely to offer satisfactory biomedical
stabilization or 24hour observation. Generally speaking, triage to
inpatient care can easily be facilitated from
either setting.
Inpatient
Freestanding urgent care centers and emergency departments are outpatient settings
that are uniquely designed to address the
needs of patients in biomedical crisis. For
patients with substance use disorders, care in
these settings is not complete until successful
linkage is made to treatment that is focused
specifically on the substance use disorder. To
accomplish this, a comprehensive assessment,
taking into account psychosocial as well as
16
biomedical issues, is recommended wherever

possible.
Appreciation of the value of multidimensional
patient assessment is central to the clinicians
ability to decide which triage (linkage) options
are least restrictive and most cost-effective
for a given patient.
Staffing
Both emergency departments and freestanding
urgent care units are staffed by physicians.
The same rules regarding who may provide
care apply here as they did in the discussion of
staffing of office-based detoxification (ASAM
2001). An RN or other licensed and credentialed nurse is available for primary nursing
care and observation. Psychologists, social
workers, addiction counselors, and acupuncturists usually are not available in these settings. The physician or attending nurse usually
facilitates linkage to substance abuse treatment.
Freestanding Substance Abuse

Treatment or Mental Health
Facility
Freestanding substance abuse treatment facilities may or may not be equipped to provide
adequate assessment and treatment of cooccurring psychiatric conditions and biopsychosocial problems, as the range of services
varies considerably from one facility to another. Inpatient mental health facilities, on the
other hand, are able generally to provide treatment for substance use disorders and co-occurring psychiatric conditions. Nonetheless, like
substance abuse treatment facilities, the range
of available services varies from one mental
health facility to another.
General guidelines for considering patient
placement in either of these settings are provided below; however, it should be emphasized that a clear understanding of the specific services that a given setting provides is
Chapter 2
indispensable to identifying the least restrictive and most cost-effective treatment option
that may be available. Concern for safety is
of primary importance, and the final decision
regarding placement always rests with the
treating physician.
Level of care
Medically Monitored Inpatient
Detoxification
Inpatient detoxification provides 24-hour
supervision, observation, and support for
patients who are intoxicated or experiencing
withdrawal. Since this level of care is relatively
more restrictive and more costly than a residential treatment option, the treatment mission
in this setting should be clearly focused and
limited in scope. Primary emphasis should be
placed on ensuring that the patient is medically
stable (including the initiation and tapering of
medications used for the treatment of substance use withdrawal); assessing for adequate
biopsychosocial stability, quickly intervening to
establish this adequately; and facilitating effective linkage to and engagement in other appropriate inpatient and outpatient services.
Inpatient settings provide medically managed
intensive inpatient detoxification. At this level
of care, physicians are available 24 hours per
day by telephone. A physician should be
available to assess the patient within 24 hours
of admission (or sooner, if medically necessary) and should be available to provide
onsite monitoring of care and further evaluation on a daily basis. An RN or other qualified nursing specialist should be present to
administer an initial assessment. A nurse will
be responsible for overseeing the monitoring
of the patients progress and medication
administration on an hourly basis, if needed.
Appropriately licensed and credentialed staff
should be available to administer medications
in accordance with physician orders.
Clinically Managed Residential

Detoxification
Residential settings vary greatly in the level of
care that they provide. Those with intensive
medical supervision involving physicians, nurse
practitioners, physician assistants, and nurses
can handle all but the most demanding complications of intoxication and withdrawal. On the
other hand, some residential settings have minimally intensive medical oversight. Residential
detoxification in settings with limited medical
oversight often is referred to as social detoxification. (Though the social detoxification
model is not limited to residential facilities.)
Facilities with lower levels of care should have
clear procedures in place for implementing and
pursuing appropriate medical referral and
linkage, especially in the case of emergencies.
For example, a patient who is in danger of
seizures or delirium tremens needs to be
referred to the appropriate medical facility for
acute care of presenting symptoms, possibly
medicated, and then returned to a social detoxification setting for continuing monitoring and
observation. The establishment of this kind of
collaborative relationship between institutions
provides a good example of a cost-effective way
to provide adequate care to patients.
Residential detoxification programs provide
24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal. They are characterized
by an emphasis on peer and social support
(ASAM 2001). Standards published by such
groups as the Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO) and the Commission on
Accreditation of Rehabilitation Facilities
(CARF) provide further information on quality measures for residential detoxification.
Additional information is available on the
JCAHO Web site (www.jcaho.org) and the
CARF Web site (www.carf.org).
17
Staffing
Inpatient detoxification programs employ
licensed, certified, or registered clinicians who
provide a planned regimen of 24-hour, professionally directed evaluation, care, and treatment services for patients and their families.
An interdisciplinary team of appropriately
trained clinicians (such as physicians, RNs and
LPNs, counselors, social workers, and psychologists) should be available to assess and treat
the patient and to obtain and interpret information regarding the patients needs. The number and disciplines of team members should be
appropriate to the range and severity of the
patients problems (ASAM 2001).
Residential detoxification programs are
staffed by appropriately credentialed personnel who are trained and competent to implement physician-approved protocols for
patient observation and supervision. These
persons also are responsible for determining
the appropriate level of care and facilitating
the patients transition to ongoing care.
Medical evaluation and consultation should
be available 24 hours a day, in accordance
with treatment/transfer practice guidelines.
All clinicians who assess and treat patients
should be able to obtain and interpret information regarding the needs of these persons
and should be knowledgeable about the
biomedical and psychosocial dimensions of
alcohol and other drug dependence. Such
knowledge includes awareness of the signs
and symptoms of alcohol and other drug
intoxication and withdrawal, as well as the
appropriate treatment and monitoring of
those conditions and how to facilitate the
individuals entry into ongoing care. Staff
should ensure that patients are taking medications according to their physicians orders
and legal requirements (ASAM 2001).
Some residential detoxification programs are
staffed to supervise self-administered medications for the management of withdrawal. All
such programs should rely on established
clinical protocols to identify patients who
18
have biomedical needs that exceed the capacity of the facility and to identify which programs will likely have a need for transferring
such patients to more appropriate treatment
settings.
Intensive Outpatient and

Partial Hospitalization
Programs
An intensive outpatient program (IOP) or partial hospitalization program (PHP) is appropriate for patients with mild to moderate withdrawal symptoms. Thorough psychosocial
assessment and intervention should be available in addition to biomedical assessment and
stabilization. Many of these programs have
close clinical and/or administrative ties to hospital centers. When needed, triage to a higher
level of care should be easy to accomplish.
Outpatient treatment should be delivered in
conjunction with all components of detoxification.
Level of care
This level of detoxification is an organized outpatient service that requires patients to be present onsite for several hours a day. It is thus
similar to a physicians office in that ambulatory detoxification with extended onsite monitoring is provided. Unlike the physicians office, in
the IOP and PHP it is standard practice to
have a multidisciplinary team available to provide or facilitate linkage to a range of medically
supervised evaluation, detoxification, and
referral services.
Detoxification services also are provided in
regularly scheduled sessions and delivered
under a defined set of policies and procedures
or medical protocols. These outpatient services are designed to treat the patients level
of clinical severity, to achieve safe and comfortable withdrawal from mood-altering drugs
(including alcohol), and to effectively facili-
Chapter 2
tate the patients engagement in ongoing treatment and recovery (ASAM 2001).
A partial hospitalization program may occupy
the same setting (i.e., physical space) as an
acute care inpatient treatment program.
Although occupying the same space, the levels
of care provided by these two programs are
distinct yet complementary. Acute care inpatient programs provide detoxification services
to patients in danger of severe withdrawal
and who therefore need the highest level of
medically managed intensive care, including
access to life support equipment and 24-hour
medical support. In contrast, partial hospitalization programs provide services to patients
with mild to moderate symptoms of withdrawal that are not likely to be severe or lifethreatening and that do not require 24-hour
medical support. The transition from an
acute care inpatient program to either a partial hospitalization or intensive outpatient
program sometimes is referred to as a stepdown. Typically, whether these programs
share space and staff with an acute care inpatient program or are physically distinct from
a hospital structure, they have close clinical
and/or administrative ties to hospital centers.
Collaborative working relationships are indispensable in pursuing the goal of providing
patients with the most appropriate level of
care in the most cost-effective setting.
Staffing
IOPs and PHPs should be staffed by physicians who are available daily as active members of an interdisciplinary team of appropriately trained professionals and who medically
manage the care of the patient. An RN or
other licensed and credentialed nurse should
be available for primary nursing care and
observation during the treatment day.
Addiction counselors or licensed or registered
addiction clinicians should be available to
administer planned interventions according to
the assessed needs of the patient. The multidisciplinary professionals (such as physicians,
nurses, counselors, social workers, psychologists, and acupuncturists) should be available
as an interdisciplinary team to assess and

care for the patient with a substance-related
disorder, as well as patients with both a substance use disorder and a co-occurring
biomedical, emotional, or behavioral condition. Successful linkage to treatment for the
substance use disorder (in addition to
biomedical stabilization) is central to the mission of an intensive
outpatient or partial
hospitalization proSuccessful linkage
gram (ASAM 2001).
For more informato treatment for
tion, see the TIP
Substance Abuse:
Clinical Issues in
the substance use
Intensive Outpatient
Treatment [CSAT in
disorder (in
development d].
addition to
Acute Care
Inpatient
Settings
There are several
types of acute care
inpatient settings.
They include
Acute care general
hospitals
Acute care addiction treatment units
in acute care general hospitals
Acute care psychiatric hospitals
biomedical
stabilization) is
central to the
mission of an
intensive outpatient or partial
hospitalization
program.
Other appropriately
licensed chemical
dependency specialty hospitals
These settings share the ready availability of
acute care medical and nursing staff, life support equipment, and ready access to the full
resources of an acute care general hospital or
its psychiatric unit. This level of care provides
medically managed intensive inpatient detoxification (ASAM 2001).
19
Level of care
Acute inpatient care is an organized service
that provides medically monitored inpatient
detoxification that is delivered by medical and
nursing professionals. Medically supervised
evaluation and withdrawal management in a
permanent facility with inpatient beds is provided for patients whose withdrawal signs and
symptoms are sufficiently severe to require 24hour inpatient care. Services should be delivered under a set of policies and procedures or
clinical protocols designated and approved by a
qualified physician (ASAM 2001). Additional
information on acute inpatient programs is
available on the JCAHO Web site
(www.jcaho.org) and the CARF Web site
(www.carf.org).
Staffing
Acute care inpatient detoxification programs
typically are staffed by physicians who are
available 24 hours a day as active members of
an interdisciplinary team of appropriately
trained professionals and who medically manage the care of the patient. In some States,
these duties may be performed by an RN or
physician assistant. An RN or LPN, as usual, is
available for primary nursing care and observation 24 hours a day. Facility-approved addiction counselors or licensed or registered addiction clinicians should be available 8 hours a
day to administer planned interventions
according to the assessed needs of the patient.
An interdisciplinary team of appropriately
trained clinicians (such as physicians, nurses,
counselors, social workers, and psychologists)
should be available to assess and treat the
patient with a substance-related disorder, or a
patient with co-occurring substance use,
biomedical, psychological, or behavioral conditions (ASAM 2001).
20
Other Concerns
Regarding Levels of
Care and Placement
In part because of the need to keep costs to a
minimum and in part as the result of research
in the field, outpatient detoxification is becoming the standard for treatment of symptoms of
withdrawal from substance dependence in
many locales. Most alcohol treatment programs
have found that more than 90 percent of
patients with withdrawal symptoms can be
treated as outpatients (Abbott et al. 1995).
Careful screening of these patients is essential
to reserve for inpatient treatment those clients
with possibly complicated withdrawal; for
example, patients with subacute medical or
psychiatric conditions (that in and of themselves would not require hospitalization) and
those in danger of seizures or delirium tremens
should receive inpatient care. Inpatient addiction treatment programs will vary in the level
of acute medical or psychiatric care that can be
provided. Figure 2-1 presents an overview of
issues to consider in deciding between inpatient
and outpatient detoxification.
ASAM criteria are being adopted extensively
on the basis of their face validity, though
their outcome validity has yet to be clinically
proven. Early studies of more versus less
restrictive and intensive treatment settings on
randomized samples generally have failed to
show group differences, and studies continue
to show this pattern (Gastfriend et al. 2000).
Whether patients undergoing detoxification
will have better results as outpatients rather
than as inpatients remains to be established
(Hayashida 1998).
Another consideration is that ASAM placement guidelines are not always the best guide
to placing a patient in the proper setting at
the proper level. For example, what is the
clinician to do with the patient who qualifies
for outpatient treatment according to the
ASAM guidelines but is homeless in sub-zero
temperatures? No provision is made for such
cases. The ASAM guidelines are to be regardChapter 2
Figure 2-1
Issues To Consider in Determining Whether Inpatient or Outpatient
Detoxification Is Preferred
Considerations
Indications
Ability to arrive at clinic on a daily basis
Necessary if outpatient detoxification is to be carried out
History of previous delirium tremens or withdrawal seizures
Contraindication to outpatient detoxification:

recurrence likely; specific situation may suggest
that an attempt at outpatient detoxification is possible
No capacity for informed consent
Protective environment (inpatient) indicated
Suicidal/homicidal/psychotic condition
Protective environment (inpatient) indicated
Able/willing to follow treatment recommendations
Protective environment (inpatient) indicated if

unable to follow recommendations
Co-occurring medical conditions
Unstable medical conditions such as diabetes,

hypertension, or pregnancy: all relatively strong
contraindications to outpatient detoxification
Supportive person to assist
Not essential but advisable for outpatient detoxification
Source: Consensus Panelist Sylvia Dennison, M.D.

ed as a work in progress, as their authors
readily admit (ASAM 2001, p. 19).
Nevertheless, they are an important set of
guidelines that are of great help to clinicians.
For administrators, the standards published
by such groups as JCAHO and CARF offer
guidance for overall program operations.
Additional information is available on the
JCAHO Web site (www.jcaho.org) and the
CARF Web site (www.carf.org).
It has become clear that detoxification
involves much more than simply medically
withdrawing a patient from alcohol or other
drugs. Detoxification, whether done on an

inpatient, residential, or outpatient basis, frequently is the initial therapeutic encounter
between patient and clinician. Irrespective of
the substance involved, a detoxification
episode should provide an opportunity for
biomedical (including psychiatric) assessment, referral for appropriate services, and
linkage to treatment services. Chapter 3 provides an overview of the psychosocial and
biomedical issues relevant to detoxification,
strategies to engage the patient, and an
overview of providing adequate linkage to follow up treatment and services.
21
In This
Chapter
Evaluating and
Addressing
Psychosocial and
Biomedical Issues
Strategies for
Engaging and
Retaining Patients
in Detoxification
Referrals and
Linkages
3 An Overview of
Psychosocial and
Biomedical Issues
During Detoxification
Regardless of setting or level of care, the goals of detoxification are to
provide safe and humane withdrawal from substances and to foster
the patients entry into long-term treatment and recovery.
Detoxification presents a unique opportunity to intervene during a
period of crisis and move a client to make changes in the direction of
health and recovery. Hence, a primary goal of the detoxification staff
should be to build the therapeutic alliance and motivate the patient to
enter treatment. This process should begin even as the patient is being
medically stabilized (Onken et al. 1997).
Psychological dependence, co-occurring psychiatric and medical conditions, social supports, and environmental conditions critically influence the probability of successful and sustained abstinence from substances. Research indicates that addressing psychosocial issues during
detoxification significantly increases the likelihood that the patient
will experience a safe detoxification and go on to participate in substance abuse treatment. Staff members ability to respond to patients
needs in a compassionate manner can make the difference between a
return to substance abuse and the beginning of a new (and more positive) way of life.
This chapter addresses the psychosocial and biomedical issues that may
affect detoxification and ensuing treatment. It highlights evaluation procedures for patients undergoing detoxification, discusses strategies for
engaging and retaining patients in detoxification and preparing them for
treatment, and presents an overview for providing linkages to other
services.
23
Overarching Principles for Care During

Detoxification services do not offer a cure for substance use disorders. They often are a first step
toward recovery and the first door through which patients pass to treatment.
Substance use disorders are treatable, and there is hope for recovery.
Substance use disorders are brain disorders and not evidence of moral weaknesses.
Patients are treated with respect and dignity at all times.
Patients are treated in a nonjudgmental and supportive manner.
Services planning is completed in partnership with the patient and his or her social support network,
including such persons as family, significant others, or employers.
All health professionals involved in the care of the patient will maximize opportunities to promote rehabilitation and maintenance activities and to link her or him to appropriate substance abuse treatment immediately after the detoxification phase.
Active involvement of the family and other support systems while respecting the patients rights to privacy
and confidentiality is encouraged.
Patients are treated with due consideration for individual background, culture, preferences, sexual orientation, disability status, vulnerabilities, and strengths.
Evaluating and
Addressing
Psychosocial and
Biomedical Issues
Patients entering detoxification are undergoing
profound personal and medical crisis.
Withdrawal itself can cause or exacerbate current emotional, psychological, or mental problems. The detoxification staff needs to be
equipped to identify and address potential
problems.
Considerations for Conducting

the Initial Evaluation
An initial evaluation will help detoxification
staff foresee any variables that might complicate a safe and effective withdrawal. Figure 3-1
lists the biomedical and psychosocial domains
that can affect the stabilization of the patient.
The following sections include some general
guidelines and important considerations to
follow when providing detoxification services.
24
General Guidelines for

Addressing Immediate
Medical Concerns
Because substance abuse affects all systems of
the body and is associated with lack of selfcare, it is not unusual for detoxification to be
complicated by medical problems. Health professionals should screen for medical problems
that may put the client at risk for a medical crisis or expose other clients or staff to contagious
diseases. This section outlines important considerations for both nonmedical and medical
staff. Chapter 5 provides a clinical overview of
co-occurring medical conditions and is geared
primarily toward medical personnel.
Co-occurring medical
conditions
The initial consultation should include an evaluation of the expected signs, symptoms, and
severity of the withdrawal. Detoxification is not
an exact science, but any significant deviation
from the expected course of withdrawal should
be observed closely. Figure 3-2 (p. 26) provides
Chapter 3
Figure 3-1
Initial Biomedical and Psychosocial Evaluation Domains
Biomedical Domains
General health historyWhat is the patients medical and surgical history? Are there any psychiatric or medical conditions? Are there known medication allergies? Is there a history of seizures?
Mental statusIs the patient oriented, alert, cooperative? Are thoughts coherent? Are there signs of
psychosis or destructive thoughts?
General physical assessment with neurological examThis will ascertain the patients general health
and identify any medical or psychiatric disorders of immediate concern.
Temperature, pulse, blood pressureThese are important indicators and should be monitored
throughout detoxification.
Patterns of substance abuseWhen did the patient last use? What were the substances of abuse?
How much of these substances was used and how frequently?
Urine toxicology screen for commonly abused substances.
Past substance abuse treatments or detoxificationThis should include the course and number of
previous withdrawals, as well as any complications that may have occurred.
Psychosocial Domains
Demographic featuresGather information on gender, age, ethnicity, culture, language, and educational level.
Living conditionsIs the patient homeless or living in a shelter? What is the living situation? Are significant others in the home (and, if so, can they safely supervise)?
Violence, suicide riskIs the patient aggressive, depressed, or hopeless? Is there a history of violence?
TransportationDoes the patient have adequate means to get to appointments? Do other arrangements need to be made?
Financial situationIs the patient able to purchase medications and food? Does the patient have
adequate employment and income?
Dependent childrenIs the patient able to care for children, provide adequate child care, and
ensure the safety of children?
Legal statusIs the patient a legal resident? Are there pending legal matters? Is treatment court
ordered?
Physical, sensory, or cognitive disabilitiesDoes the client have disabilities that require consideration?
a list of signs and symptoms of conditions that
require immediate medical attention. All staff
members who work with patients should be
aware of these and seek medical consultation
for the patients as necessary.
Seizures are of special concern. Practitioners

should interview the patient and family about
seizure disorders and seizure history. In addition, nonmedical staff should be aware of signs
of impending seizures such as tremors,
An Overview of Psychosocial and Biomedical Issues During Detoxification
25
Figure 3-2
Symptoms and Signs of Conditions That Require Immediate
Medical Attention
Change in mental status
Increasing anxiety and panic
Hallucinations
Seizures
Temperature greater than 100.4 F (these patients should be considered potentially infectious)
Significant increases and/or decreases in blood pressure and heart rate
Insomnia
Abdominal pain
Upper and lower gastrointestinal bleeding
Changes in responsiveness of pupils
Heightened deep tendon reflexes and ankle clonus, a reflex beating of the foot when pressed rostrally
(i.e., toward the mouth of the patient), indicating profound central nervous system irritability and the
potential for seizures
increased blood pressure, overactive reflexes,
and high temperature and pulse. It is essential
that nonmedical staff be trained in protocols to
prevent injury in the event of a seizure.
Competence in carrying out these protocols
should be evaluated by a physician or nurse
clinician. For more information on seizures,
see chapter 4.
All staff working with patients should be
familiar with medical disorders that are associated with various addictive substances or
routes of administration. Alcoholism has multiple organ effects involving the liver, pancreas, central nervous system, cardiovascular
system, and endocrine system. Cocaine produces many of its medical complications
through vasoconstriction (i.e., narrowing of
the blood vessels), including myocardial
infarction (heart attack), stroke, renal disease, spontaneous abortion, and even bowel
infarction (death of tissue). Cocaine also can
cause seizures and cardiac arrhythmia (irregular heartbeat). A heroin overdose can lead
to a fatal respiratory depression. Intravenous
drug use is particularly likely to increase the
risk of infectious complications, including
26
HIV, viral hepatitis, abscesses, and sepsis (the

spreading of infection from its original site in
the body). Intrapulmonary (within the lungs)
administration can cause lung disorders
(Dackis and Gold 1991). Nonmedical detoxification staff also should be aware of the medications used in detoxification, medications for
common medical and psychiatric disorders,
and signs of common medication reactions
and interactions.
Infectious disease
Standard precautions should be used with all
patients to protect the staff and patients against
the transmission of infectious diseases, including HIV and hepatitis A, B, and C. All open
wounds should be cultured and treated to prevent the spread of infections. Providers should
use HIV/blood and respiratory infection precautions until HIV and respiratory infectious
status are known. Patients with respiratory
infections should be carefully evaluated. The
panel suggests that tuberculin testing be performed or recent test results obtained on all
patients to screen for active tuberculosis. A
chest x-ray is recommended if indicated by the
Chapter 3
patients history and physical assessments.

Nonmedical detoxification staff should be
trained to watch for the signs of common infectious diseases passed through casual contact,
including infestation with scabies and lice.

Addressing Immediate Mental
Health Needs
The following section provides general guidelines for treating patients who have immediate
mental health needs. For more detailed information on the treatment of patients with cooccurring psychiatric conditions see TIP 42,
Substance Abuse Treatment for Persons With
Co-Occurring Disorders (Center for
Substance Abuse Treatment [CSAT] 2005c).
Suicide
Those who are users of multiple illicit substance are more likely to experience psychiatric
disorders, and the risk is highest among those
who use both opiates and benzodiazepines
and/or alcohol (Marsden et al. 2000).
Depression is more common among those who
abuse a combination of these substances, and
women are at higher risk than men. Among
those patients who are positive for depression,
the risk of suicide is high. Marsden and colleagues 2000 study of 1,075 clients entering
treatment showed that 29 percent reported suicidal ideation in the past 3 months.
During acute intoxication and withdrawal, it
is important to provide an environment that
minimizes the opportunities for suicide
attempts. As a precaution, locations not
clearly visible to staff should be free of items
that might be used for suicide attempts.
Frequent safety checks should be implemented; the frequency of these checks should be
increased when signs of depression, shame,
guilt, helplessness, worthlessness, and hopelessness are present. When feasible, patients
at risk for suicide should be placed in areas
that are easily monitored by staff. Most
important, when interacting with patients at
risk for suicide, staff should avoid harsh confrontation and judgment and instead focus on
the treatable nature of substance use disorders and the rehabilitation options available.
These interactions offer an opportunity to
start a dialog with the patient regarding the
impact of substance use on mental illness and
vice versa.
Anger and aggression

Alcohol, cocaine, amphetamine, and hallucinogen intoxication may be associated with
increased risk of violence. Symptoms associated with this increased risk for violence
include hallucinations, paranoia, anxiety, and
depression. As a precaution, all patients who
are intoxicated should be considered potentially violent (Miller et al. 1994). Programs
should have in place well-developed plans to
promote staff and patient safety, including
protocols for response by local law enforcement agencies or security contractors. Staff
working in detoxification programs should be
trained in techniques to de-escalate anger and
aggression. In many cases, aggressive behaviors can be defused through verbal and environmental means (Reilly and Shopshire
2002). For the protection of the staff and the
patient, physical restraint should be used as a
last resort and programs should be aware of
local laws and regulations pertaining to physical restraint. Figure 3-3 (p. 28) lists some useful ways of managing patients who are angry
and aggressive. Readers may refer to the
standards published by such groups as the
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) and the
Commission on Accreditation of
Rehabilitation Facilities (CARF) for further
guidance. Additional information is available
on the JCAHO Web site (www.jcaho.org) and
the CARF Web site (www.carf.org). The
Administration (SAMHSA) also has published
guidelines on the use of seclusion and
restraint, which call for the reduction and
possible elimination of their use (SAMHSA
2002).
27
Figure 3-3
Strategies for De-escalating Aggressive Behaviors
Speak in a soft voice.
Isolate the individual from loud noises or distractions.
Provide reassurance and avoid confrontation, judgments, or angry tones.
Enlist the assistance of family members or others who have a relationship of trust.
Offer medication when appropriate.
Separate the individual from others who may encourage or support the aggressive behaviors.
Enlist additional staff members to serve as visible backup if the situation escalates.
Have a clearly developed plan to enlist the support of law enforcement or security staff if necessary.
Establish clear admission protocols in order to help screen for potentially aggressive/violent patients.
Determine ones own level of comfort during interaction with the patient and respect personal limits.
Ensure that neither the clinicians nor the patients exit from the examination room is blocked.
Co-occurring mental
disorders
With the patients consent, a review of the
patients mental health history with the patient
and family is useful in identifying co-occurring
psychiatric conditions. Mental health professionals caring for the client should be consulted. If a pharmacy profile on the patient is
available, it should be copied for review (within
the confines of State and Federal confidentiality laws).
Diagnosis of co-occurring substance-related
disorders and mental conditions is difficult
during acute intoxication and withdrawal
because it often is impossible to be precise until
the clinical picture allows for the full assessment of both the effects of substance use and of
the symptoms of mental disorders. As the individual moves from severe to moderate withdrawal symptoms, attention to differential
diagnosis of substance use disorders and other
psychiatric disorders becomes a priority (First
et al. 2002). The American Psychiatric
Association (APA) and the American Society of
Addiction Medicine (ASAM) guidelines recommend a period of 2 to 4 weeks of abstinence
before attempting to diagnose a psychiatric disorder (APA 2000; ASAM 2001).
28

Addressing Nutritional
Concerns
Malnutrition is a major concern for patients
entering detoxification because the nutrient
deficiencies associated with substance abuse
can interfere with or even prolong the detoxification process (Nazrul Islam et al. 2001).
Longstanding irregular eating habits and poor
dietary intake only exacerbate the problem
(Pelican et al. 1994). The detoxification process
itself is stressful to the body and may result in
increased nutrient requirements. Proper nutrition during recovery improves to a significant
extent the adverse effects of the substance
abuse (Nazrul Islam et al. 2001).
Nutritional evaluation
An evaluation of nutritional status should be a
core component of detoxification. It should be
noted, however, that for patients who abuse
alcohol, the administration of fluids to address
dehydration should be the first step, with
nutritional evaluation occurring after the
patient is adequately hydrated.
Chapter 3
The nutritional evaluation should consist of

laboratory and anthropometric indices, a
detailed nutritional history, and nutrition
counseling (Simko et al. 1995). The intervention begins in the initial acute phase of withdrawal and continues through detoxification
and subsequent substance abuse treatment. If
the patient consents, family members or significant others may be included in the nutritional
evaluation and counseling.
Weight is an important consideration in determining the nutritional status of the person with
a substance use disorder. Substance abuse may
result in a reduction in food intake and disruption in the patients metabolism that may in
turn have caused an eating disorder, weight
loss, and malnutrition. Conversely, weight gain
may be related to inactivity and an excessive
intake of highly refined carbohydrates (Zador
et al. 1996). Patients should be asked whether
there have been any recent changes in their
weight. While a patient may appear to be adequately nourished, a skinfold caliper (an
instrument that measures the thickness of a
fold of skin with its underlying layer of fat) can
determine body density (the relationship of the
bodys mass to its volume), though the body
mass index may be a better indicator of nutritional status (Simko et al. 1995).
Other questions to ask during the initial evaluation concern appetite, eating patterns, food
preferences, snacking habits, food allergies,
food intolerance, special diets, and foods to be
avoided because of cultural or religious beliefs.
A food frequency questionnaire, food diary, or
24-hour food recall may be of use.
Many drug addictions are associated with
abnormal glucose (sugar) metabolism. This
abnormality means that the body is unable to
maintain a stable concentration of glucose in
the blood. Abnormally high or low blood sugar
levels easily can be confused with the signs and
symptoms of alcohol intoxication or withdrawal; consequently, a check of blood glucose level
is particularly important in patients with a history of blood sugar abnormalities. Hypoglycemia (low levels of blood sugar) in the person
with a substance use disorder may lead to drastic mood changes. When blood glucose levels
drop below a certain threshold, these patients
usually feel depressed, anxious, or moody and
may experience cravings for their drug of
choice.
Nutritional deficits
associated with specific
substances
As noted, the abuse of drugs can interfere with
nutrient utilization and storage. Detoxification
personnel should be familiar with the nutritional deficits associated with specific substances.
Opioids are known to decrease calcium absorption and to increase cholesterol and body
potassium levels. Magnesium deficiency often is
seen in chronic alcohol dependence. Other
nutrient deficiencies seen in alcohol abuse
include protein, fat, zinc, calcium, iron, vitamins A and E, and the water-soluble vitamins
pyridoxine, thiamine, folate, and vitamin B12
(Nazrul Islam et al. 2001). Alcohol also contains calories (7 kcal/gm) that when consumed
in excessive amounts may displace nutrientdense foods. Cocaine is an appetite suppressant
and may interfere with the absorption of calcium and vitamin D. Laboratory tests for protein, vitamins, and iron and the other electrolytes are recommended to determine the
extent of liver function as well as supplementation (Fontaine et al. 2001). Caution should be
exercised when using supplements because of
their potential interactions with other drugs
and treatments.
Addressing nutritional
deficits
Detoxification should include efforts to address
nutritional deficits and to begin the patient on
a course of improved eating habits. It is crucial
to switch the paradigm from ingesting substances harmful to the body to taking in foods
that heal the body (Nebelkopf 1981, 1987,
1988). The regularity of meal times, taste, and
presentation are important considerations.
29
Attractively arranged, pleasant-tasting food

may inspire the patient to consume vital nutrients and adequate calories. It is important that
during the detoxification process, the patient
avoid substituting one addiction for another.
Consuming excessive amounts of caffeine or
sugar can compromise the process and lead to
relapse. Patients should be offered only decaffeinated beverages and healthful snacks instead
of refined carbohydrates such as sugar-based
sweets like candy, cookies, or donuts. Fresh
fruits, vegetables, and other whole foods can
contribute to the individuals health and wellness.
Gastrointestinal disturbances (i.e., nausea,
vomiting, and diarrhea) may accompany the
first phase of detoxification. Such disturbances can worsen dehydration and may disturb blood chemistry balance, which in turn
can lead to mental status changes, neurological or heart problems, and other potentially
dangerous medical conditions. Patients with
gastrointestinal disturbances may only be
able to tolerate clear liquids. When solid
foods are tolerated, balanced meals consisting
of low-fat foods, with an increased intake of
protein (meat, dairy products, legumes), complex carbohydrates (whole grain bread and
cereals), and dietary fiber are recommended
(Duyff 1996). Patients undergoing detoxification may also experience constipation.
Increasing the fiber content of the diet will
help to alleviate this discomfort.
Considerations for patients

with special dietary
requirements
Patients with special dietary requirements need
additional nutrition therapy. A person with
diabetes, for example, should follow the dietary
guidelines of the American Diabetes
Association, which emphasizes individualized
meal planning (American Diabetes Association
2004). A patient who is a vegetarian may have
additional nutritional deficiencies, especially if
she or he is a vegan (i.e., a person who avoids
eating all foods derived from animals, including
30
milk products and eggs). If a vegan enters

detoxification with marginal or low nutrient
stores, his or her diet should be augmented
with legumes, meat analogs, textured vegetable
protein, nuts, and seeds. Many other medical
conditions (e.g., ulcers, heart disease, food
allergies, etc.) may require special diets. At
intake, any special dietary considerations
should be noted.
Considerations for
Intoxication and Withdrawal
in Adolescents
Generally, detoxification is the same for adolescents as it is for adult clients. However, there
are a few important and unique considerations
for adolescent patients. For one, adolescents
are more likely than adults to drink large
quantities of alcohol in a short period of time,
making it is especially important that detoxification providers be alert to escalating blood
alcohol levels in these patients. Moreover, adolescents are more likely than adults to use
drugs they cannot identify, to combine multiple
substances with alcohol, to ingest unidentified
substances, and to be unwilling to disclose drug
use (Westermeyer 1997). As a result, the consensus panel recommends routinely screening
adolescent patients for illicit drug intoxication.
It also is important for staff to be trained in
how to assess for the use of PCP, which can
present with psychosis-like symptoms. Staff
should ask the adolescent directly whether he
has used PCP within the 12-hour period before
entering the clinic or treatment center.
Adolescents should be placed in a secure,
clean environment with observation and supportive care. If alcohol, heroin, or other
drugs associated with vomiting are suspected,
protecting the individuals airway and positioning the patient on his or her side to avoid
aspiration (inhaling) of stomach contents are
critical. In severe cases of ingestion of respiratory depressants, respiratory support may
be needed. If the individual is severely combative or belligerent, physical restraint may
be needed as a last resort when allowed and
Chapter 3
appropriate. In milder cases, observation in a

quiet, secure room with compassionate reassurance may be sufficient. Additionally, adolescents served in adult settings should be
separated from the adult population and
observed closely to ensure that they are not
victimized (i.e., verbally, physically, or sexually) by adult clients. Finally, adolescents in
detoxification settings should always be
screened carefully for suicide potential and
co-occurring psychiatric problems.
Considerations for Victims of

Domestic Violence
It sometimes is challenging to establish rapport with adolescents, as their experience

with adults may be marked by adverse consequences. Asking open-ended questions and
using street terminology for drugs and other
expressions commonly used by teenagers can
be helpful both in establishing rapport and in
obtaining an accurate substance use history.
For more information on working with adolescents, see TIP 31, Screening and Assessing
Adolescents for Substance Use Disorders
(CSAT 1999d), and TIP 32, Treatment of
Adolescents With Substance Use Disorders
(CSAT 1999f).
If a patient discloses
a history of domestic
Ensuring that
violence, trained
staff can help the
children have a
victim create a longterm safety plan or
safe place to stay
make a proper referral. If a safety plan
while their
is made or phone
numbers for domesmothers are in
tic violence help are
provided, related
information should
detoxificaton is of
be labeled carefully
so as not to disclose
vital importance.
its purpose (e.g., listed as womens health
resources) since the
abuser may go
through all personal
belongings. All printed information about domestic violence also
should be disguised and none should be kept
by the patient when she leaves the safe facility. If the victim needs to press charges or
obtain a restraining order, this should be
done from a safe setting (e.g., inpatient detoxification). If at all possible, the victim should
be escorted to a safety shelter. It may be
important that the abused person, whether
male or female, not be allowed to talk to the
abuser while in detoxification. Parents who
are victims of domestic violence may need
help with parenting skills and securing counseling and childcare. Therefore, it is important for detoxification providers to be familiar with local childcare resources. For more
Considerations for Patients

Who Are Parents With
Dependent Children
For parentsespecially womenentering
detoxification programs, the safety of children
often is a concern and one of the biggest barriers to retention. Even if women do not have
custody of their children they often are the
ones who continue to care for them. Some children may show extreme need for their mother
while separated from her, and their demands
could trigger unauthorized leave from detoxification. Thus, ensuring that children have a
safe place to stay while their mothers are in
detoxification is of vital importance. Working
with women and men to identify supportive
family or friends may identify temporary childcare resources. A consult or referral to the
treatment facilitys social services while the
patient is being detoxified is indicated when the
care of children is uncertain.
While both men and women are victims of

domestic abuse, womens substance use is associated with increased risk of intimate partner
violence (Cunradi et al. 2002). Staff should
know the signs of domestic violence and be prepared to follow procedures to ensure the
safety of the patient.
31
information see TIP 25, Substance Abuse

Treatment and Domestic Violence (CSAT
1997b).
Considerations for Culturally

Diverse Patients
In providing psychosocial supports for culturally diverse patients, cultural sensitivity is of
tremendous importance. Clients expectations
of detoxification, their feelings about the

healthcare system generally, and their social
and community support structures vary
according to their cultural backgrounds. In
working with any specific population, the practitioner should avoid defining the patient in
terms of his culture, since over- or underemphasizing the patients race or ethnicity can be
detrimental (Clark et al. 1998). Figure 3-4 pro-
Figure 3-4
Questions To Guide Practitioners To Better Understand the Patients
Cultural Framework
What language do you prefer we use?
Therapists and clients sometimes have different ideas about diseases, can you tell me more about
your idea of why you are in detoxification now?
Do you require assistance for daily living activities (such as personal hygiene, shopping, paying bills,
etc.)?
What do you call your present condition/situation (as it relates to substance use)? How does your
family view your present condition/situation (as it relates to substance use)?
What is the role of alcohol or drugs in your family?
How does your community view your present condition/situation (as it relates to substance use)? Or
what is the role of alcohol or drugs in your community?
How has your present condition/situation (as it relates to substance use) altered your status in the
community?
What experiences have you had with the healthcare system?
Do you think your substance use is a problem for you?
What do you think caused your present condition/situation (as it relates to substance use)?
Why do you think it started?
What is going on in your body?
How has your present condition/situation (as it relates to substance use) altered your life?
How have you tried to solve the problem(s) associated with substance use in the past? Was it helpful?
What worked/didnt work?
Why are you coming now?
Are you on any herbal medications or special foods for this problem?
What concerns or fears do you have about your present condition/situation (as it relates to substance
use)?
What concerns or fears do you have about this treatment?
Source: Adapted from Tang and Bigby 1996; Thurman et al. 1995.
32
Chapter 3
vides clinicians with some helpful questions to

guide their discussions.
Considerations for Chronic

Relapsers
A patient who recently relapsed after a period
of extended abstinence may feel especially
hopeless and vulnerable (an abstinence violation effect). In this situation, clinicians can
acknowledge progress that had been made
prior to relapse and reassure the patient that
the internal gains from past recovery work
have not all been lost (despite the feeling at the
moment that they have), perhaps reframing the
severity of emotional pain as an indicator of
how important recovery is to the patient.
Strategies for
Engaging and
Retaining Patients in
Detoxification
It is essential to keep patients who enter detoxification from falling through the cracks
(Kertesz et al. 2003). Successful providers
acknowledge and show respect for the patients
pain, needs, and joys, and validate the
patients fears, ambivalence, expectation of
recovery, and positive life changes. It is essential that all clinicians who have contact with
patients in withdrawal continually offer hope
and the expectation of recovery. An atmosphere that conveys comfort, relaxation, cleanliness, availability of medical attention, and
security is beneficial to patients experiencing
the discomforts of the withdrawal process.
Throughout the detoxification experience,
detoxification staff should be unified in their
message that detoxification is only the beginning of the substance abuse treatment process
and that rehabilitation and maintenance activities are critical to sustained recovery.
Educate the Patient on the

Withdrawal Process
During intoxication and withdrawal, it is useful
to provide information on the typical withdrawal process based on the particular drug of
abuse. Usually withdrawal includes symptoms
that are the opposite of the effects of the particular drug. This rebound effect can cause anxiety and concern for patients. Providing information about the common withdrawal symptoms of the specific drugs of abuse may reduce
discomfort and the likelihood that the individual will leave detoxification services prematurely
(for a list of withdrawal symptoms, see chapter
4). Settings that routinely encounter individuals in withdrawal should have written materials
available on drug effects and withdrawal from
specific drugs, and have staff who are well
versed in the signs and symptoms of withdrawal. An additional consideration is providing
such information to nonEnglish-speaking
patients and their families.
Interventions that assist the client in identifying and managing urges to use also may be
helpful in retaining the client in detoxification
and ensuring initiation of rehabilitation.
These interventions may include cognitive
behavioral approaches that help the individual identify thoughts or urges to use, the development of an individualized plan to resist
these urges, and use of medications such as
naltrexone to reduce craving (Anton 1999;
Miller and Gold 1994).
Use Support Systems

The use of client advocates to intervene with
clients wishing to leave early often can be an
effective strategy for promoting retention in
detoxification. Visitors should be instructed
about the importance of supporting the individual in both detoxification and substance abuse
treatment. If available, and if the patient is stable, he or she can attend onsite 12-Step or
other support group meetings while receiving
detoxification services. These activities reinforce the need for substance abuse treatment
33
and maintenance activities and may provide a

critical recovery-oriented support system once
detoxification services are completed.
Maintain a Drug-Free
Environment
Maintaining a safe and drug-free environment
is essential to retaining clients in detoxification. Providers should be alert to drug-seeking behaviors, including bringing alcohol or
other drugs into the facility. Visiting areas
should be easy for the staff to monitor closely,
and staff may want to search visiting areas
and other public areas periodically to reduce
the opportunities for acquiring substances. It
is important to note, however, that personnel
should be respectful in their efforts to maintain a drug-free environment. It is important
to explain to patients (prior to treatment) and
visitors why substances are not allowed in the
facility.
Consider Alternative
Approaches
Alternative approaches such as acupuncture
are safe, inexpensive, and increasingly popular
in both detoxification and substance abuse
treatment. Although the effectiveness of alternative treatments in detoxification and treatment has not been validated in well-controlled
clinical trials, if an alternative therapy brings
patients into detoxification and keeps them
there, it may have utility beyond whatever specific therapeutic value it may have
(Trachtenberg 2000). Other treatments that
reside outside the Western biomedical system,
typically grouped together under the heading of
Complementary or Alternative Medicine, also
may be useful for retaining patients. Indeed,
given the great cultural diversity in the United
States, other culturally appropriate practices
should be considered.
Enhancing Motivation
Motivational enhancements are particularly
well-suited to accomplishing the detoxification
34
services goal of promoting initiation in rehabilitation and maintenance activities. Use of

these techniques in the detoxification setting
increases the likelihood that patients will seek
treatment by helping them understand the
adverse consequences of continued substance
use. It also establishes a supportive and nonjudgmental relationship between the substance abuse counselor and the patientthis
therapeutic alliance is an important factor in
the patients choice to seek treatment services
(Miller and Rollnick 2002). TIP 35,
Enhancing Motivation for Change in
Substance Abuse Treatment (CSAT 1999c),
covers specific interventions and techniques
to increase motivation to change substancerelated behaviors. TIP 35 also includes some
basic principles common to motivational
interventions (CSAT 1999c, p. xvii):
Focus on the patients strengths.
Show respect for a patients decisions and
autonomy; respect should be maintained
at all times, even when the patient is
intoxicated.
Avoid confrontation.
Individualize treatment.
Do not use labels that depersonalize the
patient, such as addict or alcoholic.
Empathize with the patient, making an
attempt to understand the patients perspective and accept his or her feelings.
Accept treatment goals that involve small
steps toward ultimate goals.
Assist the patient in developing an awareness
of discrepancies between her or his goals or
values and current behavior.
Listen reflectively to the patients immediate
concerns and ask open-ended questions.
In addition, the detoxification team can leverage the relationship the patient has with significant others. Using interventions such as
Community Reinforcement and Family
Training (CRAFT) (Miller et al. 1999), the
detoxification team can help significant others
in the patients life capitalize on moments
when the patient is ready for change and
Chapter 3
assist the patient in preparing for change in a

nonthreatening, nonconfrontational manner.
The consensus panel does not recommend
that clinicians use direct confrontation in
helping a person with a substance use disorder begin the process of detoxification and
subsequent substance abuse treatment.
Techniques that involve purposefully confronting patients about their substance use
behavior, such as the Johnson Intervention,
where significant others are taught to confront the individuals using substances
(Liepman 1993), have been shown to be highly effective when significant others implement
them. However, subsequent studies of clinicians, groups, and programs that rely on confrontational techniques have yielded poor
outcomes (Miller et al. 1995). Moreover, the
vast majority of significant others do not wish
to use these techniques, and for that reason
these techniques are not recommended (Miller
et al. 1999).
Care should be taken to ensure that any significant other who is involved in motivating
the patient for therapy is appropriate for this
task. Only significant others who have been
appropriately introduced to the intervention
by a clinician should participate. The presence of a trained facilitator is recommended,
either for coaching or for facilitating the
intervention. It also is important to have the
recommended treatment option readily available so if the patient agrees, admission can be
swift and seamless. Those individuals selected
to intervene should support the patients
abstinence from substances of abuse.
Furthermore, if the patient places considerable value on her or his relationships with
these significant others, success is more likely
(Longabaugh et al. 1993).
Tailoring Motivational
Intervention to Stage of
Change
transtheoretical model, also known as the

stages of change model (DiClemente and
Prochaska 1998). The interventions to
increase patient motivation for substance
abuse treatment described in TIP 35,
Substance Abuse
Treatment (CSAT
1999c) are based on
this model.
According to the
Clinicians,
model, a client is
considered to be at
groups, and
one of five stages of
readiness to change
programs that
his substance-abusing behavior, each
rely on
stage being progressively closer to sustained recovery.
confrontational
Those stages are precontemplation, contechniques have
templation, preparation, action, and
yielded poor
maintenance. The
model assumes that
outcomes.
individuals may
move back and forth
between different
stages over time. A
corollary to this
assumption is that an
individuals level of motivation is definitely
not a permanent characteristic. Rather, motivation to change can be influenced by others,
including detoxification treatment staff.
In general, the basic concept is to try to move
patients to the next stage of change. The clinician needs to identify any potential obstacles
that might hinder the patients progress
through the stages of change. The transtheoretical model is illustrated in Figure 3-5
(p. 36) and the details of each stage are
described in the text below.
Perhaps the most well-known and empirically

validated model of readiness to change that
has been applied to substance abuse is the
35
Figure 3-5
The Transtheoretical Model (Stages of Change)
Source: DiClemente and Prochaska 1998.
In the precontemplation stage, the individual

is not considering any change in substanceusing behavior in the foreseeable future.
Typically, a patient in this stage either is
unaware that his substance use is a problem
or is unwilling or too discouraged to make a
change. Often, a person in the precontemplation stage has not experienced serious consequences from substance use. During the precontemplation stage, the clinician should be
attentive for and seize upon any ambivalence
36
expressed by the patient toward substancerelated behaviors. Such ambivalence may be

more likely to emerge during initial detoxification, before the patient has returned to a
relative zone of comfort and greater denial.
For patients who are determined to remain in
the precontemplation stage, the main goal is
to get the patient to begin to consider changing. To accomplish this, the clinician might
express concern, listen to the patients per-
Chapter 3
spective, and keep the door open for further

communication regarding treatment options.
In the contemplation stage, the individual has
some awareness that substance use presents a
problem. In this stage, the patient may
express a desire or willingness to change, but
has no definite plans to do so in the near
future, which generally is considered to be
the next 2 to 6 months. Whether it is explicitly stated or not, it is thought that most individuals in this stage are ambivalent about
changing. That is, side-by-side with any
desire to change is a desire to continue the
current behavior. For patients in the contemplation stage, clinicians are advised to use
decisional balancing strategies to help the
patient move to the action stage (Carey et al.
1999). In this approach, the clinician helps
the patient to consider the positive and negative aspects of her substance abuse and has
the patient weigh them against each other
with the expectation that the scale of balance
tips in favor of adopting new behavior.
Psychoeducation on the interaction of substance abuse with other problems, including
health, legal, employment, parenting, and
mental illness, can be part of this procedure.
Helping the patient understand that ambivalent feelings about changing substance use
behaviors are normal and expected can be
particularly useful at this stage.
In the preparation stage, the patient is aware
that his substance use presents a significant
problem and desires change. Moreover, the
patient has made a conscious decision to commit himself to a behavior change. This stage is
defined as one in which the individual prepares for the upcoming change in specific
ways, such as deciding whether a formal
treatment program is needed and, if so, which
one. This stage is characterized by goal setting and making commitments to stop using,
such as informing coworkers, friends, and
family of treatment plans. For patients in the
preparation stage, clinicians should elicit the
patients goals and strategies for change and
be on the alert for signs that the patient is
ready to move into the action stage. It is criti-
cal that the clinician respond quickly to any

requests for treatment to capitalize on this
motivation before it wanes. One of the most
critically important roles the clinician can
play in this stage is to assist the patient in
developing a plan of action or a behavioral
contract, taking into account the individual
needs of the patient. As part of this process
the clinician should help the patient enlist
social support. Exploring the patients expectations regarding treatment and her role in it
is important. Finally, because of the commonly experienced difficulty in accessing treatment, the clinician should discuss with the
patient ways of maintaining motivation for
change during a possible wait for entry into a
treatment program, should the patient be
placed, for example, on a waiting list.
In the action stage, the patient is taking
active steps to change substance use behaviors. This includes making modifications to
his habits and environment, such as not
spending time in places or with people associated with drug taking behavior. These
changes may even continue to be made 3 to 6
months after substance abuse has ceased.
In the maintenance stage, the patient is working to maintain the changes initiated in the
action phase.
Fostering a Therapeutic
Alliance
The therapeutic alliance refers to the quality of
the relationship between a patient and his care
providers and is the nonspecific factor that
predicts successful therapy outcomes across a
variety of different therapies (Horvath and
Luborsky 1993). A therapeutic alliance should
be developed in the context of an ability to
form an alliance to a group of helping individualssuch as a healthy support network or
therapeutic community. A clinically appropriate relationship between the clinician and
patient that is supportive, empathic, and nonjudgmental is the hallmark of a strong therapeutic alliance.
37
Readiness to change predicts a positive therapeutic alliance (Connors et al. 2000). Strong
alliances, in turn, have been associated with
positive outcomes in patients who are dependent on alcohol (Connors et al. 1997), as well
as patients involved in methadone maintenance, on such measures as illicit drug use,
employment status, and psychological functioning. In addition, the practitioners expertise and competence instill confidence in the
treatment and strengthen the therapeutic
alliance. Emphasis also should be given to the
alliance with a social support network, which
can be a powerful predictor of whether the
patient stays in treatment (Luborsky 2000).
Given the importance of the therapeutic
alliance and the fact that detoxification often
is the entry point for patients into substance
abuse treatment services, work on establishing a therapeutic alliance ideally will begin
upon admission. Many of the guidelines listed
above for enhancing motivation apply to
establishing this rapport. Newman (1997)
makes some additional recommendations for
developing the therapeutic alliance, such as
discussing the issue of confidentiality with
patients and acknowledging that the road to
recovery is difficult. He also advises being

consistent, dependable, trustworthy, and
available, even when the patient is not. The
clinician should remain calm and cool even if
the patient becomes noticeably upset.
Practitioners should be confident yet humble
and should set limits in a respectful manner
without engaging in a power struggle. See
Figure 3-6 for a list of characteristics most
valuable to a clinician in strengthening the
therapeutic alliance.
Referrals and Linkages

Once an individual passes through the most
severe of the withdrawal symptoms and is safe
and medically stable, the focus of the psychosocial interventions shifts toward actively preparing her for substance abuse treatment and
maintenance activities. These interventions
include (1) assessment of the patients characteristics, strengths, and vulnerabilities that will
influence recommendations for substance
abuse treatment; (2) preparing the patient to
participate in treatment; and (3) successfully
linking the patient to treatment as well as other
needed services and resources.
Figure 3-6
Clinicians Characteristics Most Important to the Therapeutic Alliance
Is supportive, empathic, and nonjudgmental
Knows which patients can be engaged and which should be referred to another treatment provider
Can establish rapport with any client
Remembers to discuss confidentiality issues
Acknowledges challenges on the road to recovery
Is consistent, trustworthy, and reliable
Remains calm and cool even when a client is upset
Is confident but humble
Sets limits without engaging in a power struggle
Recognizes the clients progress toward a goal
Encourages self-expression on the part of the client
38
Chapter 3
Ensuring that patients with substance use disorders enter substance abuse treatment following detoxification often is difficult. Many
patients believe that once they have eliminated the substance or substances of abuse from
their bodies, they have achieved abstinence.
Moreover, some insurance policies may not
cover treatment, or only offer partial coverage. The patient may have to go through cumbersome channels to determine if treatment is
covered, and if so, how much.
Preparation should focus on eliminating
administrative barriers to entering substance
abuse treatment prior to discussing treatment
options with the patient. Discussions with the
patient should be consistent with the patients
improving ability to process and assess information in such a way that the patient appears
to be acting with his or her own interests in
mind.
Evaluation of the Patients

Rehabilitation Needs
To make appropriate recommendations for
ongoing treatment and recovery activities,
detoxification staff need to determine the
individual characteristics of clients and their
environments that are likely to influence the
level of care, setting, and specialized services
needed for recovery. ASAMs Patient
Placement Criteria, Second Edition, Revised
(PPC-2R) (ASAM 2001) provides one widely
used model for determining the level of services needed to address substance-related disorders. The levels of treatment services range
from community-based early intervention
groups to medically managed intensive inpatient services. As noted in chapter 2,
providers need to make a placement decision
based on six dimensions:
1. Acute Intoxication and/or Withdrawal
Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive
Conditions or Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued

Problem Potential
6. Recovery/Living Environment
Due to the limited time patients stay in detoxification settings, it is challenging for programs to
conduct a complete assessment of the rehabilitation needs of the individual. With this in
mind, detoxification programs should focus on
those areas that are essential to make an
appropriate linkage to substance abuse treatment services. The assessment of the psychosocial needs affecting the rehabilitation process
itself may have to be left to the professionals
providing substance abuse treatment. Other
assessment considerations include
Special needs, such as co-occurring psychiatric and medical conditions that may complicate treatment or limit access to available
rehabilitation services
Pregnancy, physical limitations, and cognitive impairments that limit the settings suitable for the individual
Support system issues such as family support, domestic violence, and isolation that
influence recommendations about residential versus outpatient settings
The needs of dependent children
The need for gender-specific treatment (for
more information see the forthcoming TIPs
Substance Abuse Treatment: Addressing
the Specific Needs of Women [CSAT in
development e] and Substance Abuse
Treatment: Mens Issues [CSAT in development g]).
Figure 3-7 (p. 40) outlines the areas the consensus panel recommends for assessment to determine the most appropriate rehabilitation plan.
Appendix C lists a variety of instruments useful in characterizing the addiction and related
disorders (for example, the Addiction
Severity Index [ASI]), measuring motivational willingness to change (Stages of Change
Readiness and Treatment Eagerness Scale
[SOCRATES] and University of Rhode Island
Change Assessment [URICA]), and evaluating
co-occurring psychiatric conditions and social
39
Figure 3-7
Recommended Areas for Assessment To Determine Appropriate
Rehabilitation Plans
Domain
Description
Medical Conditions and

Complications
Infectious illnesses, chronic illnesses requiring intensive or specialized treatment, pregnancy, and chronic pain
Motivation/Readiness to
Change
Degree to which the client acknowledges that substance use behaviors are a
problem and is willing to confront them honestly
Physical, Sensory, or
Mobility Limitations
Physical conditions that may require specially designed facilities or staffing
Relapse History and

Potential
Historical relapse patterns, periods of abstinence, and predictors of abstinence; client awareness of relapse triggers and craving
Substance
Abuse/Dependence
Frequency, amount, and duration of use; chronicity of problems; indicators of

abuse or dependence
Developmental and
Cognitive Issues
Ability to participate in confrontational treatment settings, and benefit from

cognitive interventions and group therapy
Family and Social

Support
Degree of support from family and significant others, substance-free friends,

involvement in support groups
Co-Occurring Psychiatric
Disorders
Other psychiatric symptoms that are likely to complicate the treatment of the
substance use disorder and require treatment themselves, concerns about
safety in certain settings (note that assessment for co-occurring disorders
should include a determination of any psychiatric medications that the patient
may be taking for the condition)
Dependent Children
Custody of dependent children or caring for noncustodial children and

options for care of these children during rehabilitation
Trauma and Violence
Current domestic violence that affects the safety of the living environment, cooccurring posttraumatic stress disorder or trauma history that might complicate rehabilitation
Treatment History
Prior successful and unsuccessful rehabilitation experiences that might influence decision about type of setting indicated
Cultural Background
Cultural identity, issues, and strengths that might influence the decision to
seek culturally specific rehabilitation programs, culturally driven strengths or
obstacles that might dictate level of care or setting
Strengths and Resources
Unique strengths and resources of the client and his or her environment
Language
Language or speech issues that make it difficult to communicate or require an

interpreter familiar with substance abuse
40
Chapter 3
and family factors. Administering these

instruments requires varying degrees of
sophistication on the part of the clinician. All
instruments should be considered for their
cultural, linguistic, level of cognitive comprehension, and developmental appropriateness
for each patient. For further information on
patient placement see TIP 13, The Role and
Current Status of Patient Placement Criteria
in the Treatment of Substance Use Disorders
(CSAT 1995h).
Settings for Treatment

Just as with settings for detoxification, settings where substance abuse treatment is provided often are confused with the level of
intensity of the services. It is increasingly
clear that although level of intensity of services and setting are both critical to successful recovery, they are two separate dimensions to be considered when linking clients to
treatment. This process has been called delinking or unbundling and generally
involves determining the need for social services independently from the clinical intensity
(Gastfriend and McLellan 1997; McGee and
Mee-Lee 1997).
Treatment and maintenance activities are
offered in a variety of settings. These include
settings specifically designed to deliver substance abuse treatment, such as freestanding
substance abuse treatment centers, as well as
settings operating for other purposes, including mental health centers, jails and prisons,
and community corrections facilities.
Descriptions of these settings appear below:
Inpatient programs for treatment of substance abuse generally are delivered in hospitals and freestanding clinics and provide
24-hour nursing care in addition to intensive treatment for substance-related problems.
Residential treatment programs normally
provide 24-hour supervision by nonmedical
staff and the availability of medical staff
may be limited. These programs deliver
highly intensive substance abuse counseling

and clients may participate in the upkeep of
facilities. Peer support is critical to the
treatment delivered. As a general rule,
patients will stay at a residential treatment
facility for 7 to 30 days.
Therapeutic communities (TCs) usually
have 24-hour supervision by nonmedical
staff or clients who have sustained recovery. They tend to provide highly intensive
counseling services and rely on peer support and confrontation to shape behaviors
of clients. The TC is based on concepts of
self-help. Residence in a TC is longer than a
patients stay in a residential program
patients usually stay for a period of at least
30 days and often 6 months to a year. In
some special situations, such as a criminal
justice setting, TC residence can last 2
years or more.
Transitional residential programs and
halfway houses ordinarily have 24-hour
supervision from nonmedical staff or clients
who have sustained recovery. Patients in
these programs often are working and participate in counseling and peer support during the evening and weekend hours.
Partial hospitalization and day treatment
programs use a combination of medical and
nonmedical staff to deliver a high intensity
of counseling services during daytime
hours. Patients return home in the
evenings.
Intensive outpatient programs usually are
delivered by nonmedical staff in a clinic
location. Patients receive 6 to 9 hours of
counseling services each week in two or
three contacts.
Traditional outpatient services typically are
delivered by counselors in a clinic or office
setting and provide fewer hours of services
than the intensive outpatient programs.
Recovery maintenance activities are not
treatment but are highly valuable for ongoing sobriety maintenance. They include 12Step and other support groups aimed at
maintaining the gains accomplished in treat-
41
ment settings. Oxford House establishments

and other clean and sober living environments are among the resources that clinicians should explore and perhaps incorporate in maintenance activities.
Provide Linkage to Treatment

and Maintenance Activities
Approximately half of those making an
appointment for treatment do not appear for
their first appointment and another 20 percent or more fail to appear for the second
appointment (Gottheil et al. 1997; Parker
2002). As patients near completion of detoxification, whether they take the next step and
enter treatment is dependent on a number of
variables. Patients who are employed, are
motivated beyond the precontemplation stage,
and have family and social support, as well as
those with co-occurring psychiatric conditions, are more likely to initiate treatment.
Conversely, those who have severe drug
dependence and those who are older are less
likely to follow through and enter treatment
(Kirchner et al. 2000; Weisner et al. 2001).
Women are more likely to initiate treatment
after detoxification than men, and individuals
who have health insurance that features a
behavioral health carve-out and lower costsharing requirements are more likely to enter
treatment than those who do not (Mark et al.
2003b). Kleinman and associates (2002) followed 279 opioid- and cocaine-dependent
patients who had been in detoxification programs to determine how many had entered
substance abuse treatment 30 days after leaving the detoxification program. They found
that those who were on parole, homeless, or
who had been using drugs for less than 20
years were more likely than others to have
entered treatment.
Research indicates that patients are more
likely to initiate and remain in rehabilitation
if they believe the services will help them with
specific life problems (Fiorentine et al. 1999).
Figure 3-8 suggests strategies that detoxification personnel can use with their patients to
promote the initiation of treatment and maintenance activities.
Provide Access to Wraparound

Services
Patients are more likely to engage in treatment
if they believe the full array of their problems
Figure 3-8
Strategies To Promote Initiation of Treatment and
Maintenance Activities
Perform assessment of urgency for treatment.
Reduce time between initial call and appointment.
Call to reschedule missed appointments.
Provide information about what to expect at the first session.
Provide information about confidentiality.
Offer tangible incentives.
Engage the support of family members.
Introduce the client to the counselor who will deliver rehabilitation services.
Offer services that address basic needs, such as housing, employment, and childcare.
Source: Carroll 1997; Fehr et al. 1991.
42
Chapter 3
will be addressed, including those needs typically addressed by wraparound services (e.g.,
housing, vocational assistance, childcare,
transportation) (Fiorentine et al. 1999).
Moreover, patients receiving needed
wraparound services remain in substance
abuse treatment longer and improve more than
people who do not receive such services (Hser
et al. 1999).
As the individual passes through acute intoxication and withdrawal, it is important to
ensure that the basic needs of the patient are
met after discharge. These needs include
access to a safe, stable, and drug-free living
environment if possible; physical safety; food
and clothing; ongoing health and prenatal
care; financial assistance; and childcare.
Ensuring access to these basic needs may be
problematic, and staff must be flexible and
creative in finding the means to meet the
basic needs of the patient.
Clearly, services planning should extend
beyond the issues of substance dependence to
other areas that may affect compliance with
rehabilitation. Detoxification providers
should be familiar with available resources
for legal assistance, dental care, support
groups, interpreters, housing assistance,
trauma treatment, recovery-sensitive parenting groups, spiritual and cultural support,
employment assistance, and other assistance
programs for basic needs. Family and other
support systems also can be helpful to the
patient in accessing services and should take
part in the services planning as often as possible, always with the patients consent.
To address the needs of homeless and indigent
patients, detoxification providers should be
familiar with emergency shelters, cash assistance, and food programs in their communities and should have established referral relationships. Assessing women, teenagers, older
adults, and other vulnerable individuals for
victimization by another member of the
household also is important. Patients should
be linked with prenatal and primary health
care for domestic violence. Ideally, linkage to
these programs includes more than a phone

number; detoxification staff should assist
patients in scheduling initial appointments
and arranging for transportation.
Linkage to primary health and prenatal care
as well as to community resources is essential
for individuals with substance use disorders.
Linkages can be an effective mechanism to
assist the patient in accessing these services if
they are not available as a part of the detoxification program. Formalized referral
arrangements through contracts or memoranda of understanding can be useful to specify
organizational obligations (DAunno 1997).
Minimize Access Barriers

An integral part of the process of linking an
individual with rehabilitation and treatment
resources is to address access barriers.
Transportation, child care during treatment,
the potential for relapse between detoxification
discharge and treatment admission, housing
needs, and safety issues such as possible
domestic violence should be addressed through
an individualized plan prior to discharge.
The problem of a patients placement on a
waiting list presents a special barrier to treatment. The solution lies in developing strategies to maintain motivation for treatment during the waiting period.
For pregnant women and patients with dependent children, the threat of Child Protective
Services removing their children for abuse
and neglect due to drug use can be a barrier
to entering a treatment program.
Additionally, interacting with hostile or
unfriendly practitioners and encountering
resistance from family, partners, or friends
can be barriers to treatment entry.
Detoxification staff should be knowledgeable
about State laws regarding drug use during
pregnancy and definitions of child abuse and
neglect in order to be able to reassure and
encourage women to enter treatment.
43
People who identify as having a physical or

cognitive disability also face special barriers
to treatment. The reader is referred to TIP
29, Substance Use Disorder Treatment for
People With Physical and Cognitive
Disabilities (CSAT 1998g) and TIP 36,
Child Abuse and Neglect Issues (CSAT
2000d), for more information on these topics.
For racial/ethnic minorities, access barriers
can be compounded by language, cultural,
and financial factors. The ability of programs
to develop culturally specific interventions,
train staff and interpreters to respond to the
specific needs of these individuals, and be
aware of cultural differences in the manifestation of symptoms is critical to improving
access to care. Supervision of staff and training in cross-cultural issues is equally important to all programs serving diverse patient
populations. The forthcoming TIP Improving
Cultural Competence in Substance Abuse
Treatment (CSAT in development a) contains
more information on this topic.
Use Case Management

Case management presents an opportunity to
tailor services to individual client needs and
to minimize barriers to these services
(Gastfriend and McLellan 1997). Case management is a set of services managed to assist
the client in accessing needed resources. It is
a useful strategy to ensure that access to
wraparound services such as employment,
housing, health care, and basic needs are met
along with minimizing barriers to accessing
substance abuse treatment. As outlined in
TIP 27, Comprehensive Case Management for
Substance Abuse Treatment (CSAT 1998a),
the common functions of case management
are defined as assessment, planning, linkage,
monitoring, and advocacy. Case managers
can facilitate the critical linkage between
detoxification services and rehabilitation by
providing transportation to the rehabilitation
facility, arranging for childcare, or assisting
with housing needs. Additionally, case management is a widely used strategy to integrate
44
mental health and substance abuse treatment

for those with co-occurring conditions (Drake
and Mueser 2000).
Linkage to Ongoing
Psychiatric Services
Although it is important to make referrals for
ongoing psychiatric attention, the presence of
psychological symptoms should not prevent
detoxification staff from referring patients to
substance abuse treatment. Individuals with
co-occurring psychiatric conditions appear to
be able to initiate and benefit from substance
abuse treatment like individuals without psychiatric conditions (Joe et al. 1995).
Since some psychiatric illnesses may affect
drug cravings in patients who are substance
dependent, it is important to ensure that both
the psychiatric condition and the substance
use disorder are addressed in rehabilitation
(Anton 1999). Individuals who are taking psychotropic medications should be counseled
about the importance of continuing on these
medications. Whenever possible, discharge
from the detoxification services should be
coordinated with the patients mental health
provider in the community, and the patient
should have an appointment scheduled at the
time of discharge from the detoxification
facility. Detoxification providers should
request that the patient sign appropriate
releases of information to provide assessment
and other material to the mental health
provider to promote continuity of care. This
should only occur when the patient is medically stabilized and is in such a state of mind
that he or she can make coherent decisions in
this regard (e.g., while intoxicated, patients
should not be permitted to sign releases).
For individuals with serious co-occurring psychiatric conditions, integrated treatment for
substance use disorders and mental illness is
recommended. Case management services as
described above may be especially important
for individuals with severe mental illness
impeding their ability to access services on
their own. Increasingly, substance abuse and
Chapter 3
mental health providers are implementing

models using clinicians trained to deliver both
substance abuse and mental health treatment
concurrently (Drake and Mueser 2000). For
more information, see TIP 42, Substance
Abuse Treatment for Persons With CoOccurring Disorders (CSAT 2005c).
Linkage to Followup
Medical Care
The patients consent should be sought to
involve her or his primary healthcare provider
in the coordination of care. Patients with
chronic medical conditions and those in need of
followup care should have an appointment
made for followup medical care before leaving
the detoxification setting (Luborsky et al.
1997).
Considerations for Individuals

With Chronic Substance
Dependence
approaches may not be effective. In some

cases, addressing other needs may provide an
avenue to engage the individual with chronic
substance dependence in treatment. Case
management approaches can be successful at
addressing the need for housing, health care,
and basic needs even though the individual is
not yet willing to confront the issue of drinking or other drug use (Cox et al. 1998). TIP
27, Comprehensive Case Management for
Substance Abuse Treatment (CSAT 1998a),
provides additional information about delivery of case management services to homeless
individuals with substance use disorders and
those with other complex problems.
Documentation of repetitive inappropriate
use of voluntary detoxification services may
help pave the way for civil commitment to
involuntary treatment where this is an option,
and, where detoxification resources are limited, treatment systems need to be creative in
designing care plans for patients seeking frequent detoxification without evidence of any
therapeutic benefit.
For individuals with substance abuse problems who detoxify regularly but have limited
periods of abstinence, traditional treatment
45
In This
Chapter
Psychosocial and
Biomedical
Screening and
Assessment
Alcohol
Intoxication and
Withdrawal
4 Physical
Detoxification
Services for
Withdrawal From
Specific Substances
Opioids
Benzodiazepines
and Other
SedativeHypnotics
Stimulants
Inhalants/Solvents
Nicotine
This chapter highlights specific treatment regimens for specific substances and provides guidance on the medical, nursing, and social services aspects of these treatments. It also includes considerations for specific populations. Although it is written principally for healthcare professionals, some professionals without medical training may find it of use.
To accommodate a broad audience, the chapter includes definitions for
technical terms that may be unfamiliar to some readersfor example,
the patient was afebrile (without fever).
Marijuana and
Other Drugs
Containing THC
Psychosocial and Biomedical

Screening and Assessment
Anabolic Steroids
This section covers more complex psychosocial and biomedical assessments that may occur after initial contact as an individual undergoes
detoxification. Psychosocial and biomedical screening and services are
closely associated: neither is likely to succeed without the other, as the
case study below illustrates.
Club Drugs
Management of
Polydrug Abuse:
An Integrated
Approach
Alternative
Approaches
Considerations for
Specific
Populations
Although the medical issues in this case indicate that the patient could
successfully be managed as an outpatient, careful assessment of psychosocial and biomedical aspects of the patients condition, including
lack of transportation, the risk of violence, and his inability to carry out
routine medical instructions, strongly indicated that the patient remain
in a 24-hour supervised setting such as a residential detoxification or
treatment program. For an illustration of some of the fundamental
47
Case Study
A 44-year-old Caucasian male with a fifth-grade education presented to an emergency clinic in mild alcohol
withdrawal with no alcohol for 9 hours. The patient was mildly tremulous with some nausea and insomnia;
blood pressure was 142/94; pulse was 96. The patient was afebrile [i.e., without fever], and Clinical
Institute Withdrawal Assessment for Alcohol (CIWA-Ar) (see below) score = 12, indicating mild withdrawal.
A treatment plan was recommended that called for an outpatient 3-day fixed-dose taper of lorazepam (a
benzodiazepine medication) plus multivitamins and oral thiamine. The patient was instructed to return
daily for brief assessment by nursing personnel. The social worker assigned to this client pointed out that
there was no reliable transportation to the clinic, there had been domestic violence on the parts of both
spouses, and the patients ability to carry out routine medical instructions was questionable.
aspects of the patients health and psychosocial
status that should be covered in screening and
assessment, see Figure 3-1, p. 25.
Figure 4-1 lists several instruments useful in
characterizing the intensity of specific withdrawal states (see appendix C for more information on these instruments and how to obtain
them).
Biochemical Markers and

Their Use
This section focuses on biochemical laboratory tests that detect the presence or absence of
alcohol or another substance of abuse, may
be able to quantify the level of present use, or
may be able to quantify cumulative use over
the past few weeks. Tests in all of these areas
are reasonably well developed and validated
for alcohol. This is not the case for most
other substances of abuse. Biochemical markers are not adequate screening or assessment
instruments alone, but rather are used to
support a more comprehensive clinical assessment. Common uses of these biochemical
markers are:
1. In the initial screening setting to support
or refute other information that leads to
proper diagnosis, assessment, and management.
2. For forensic purposes (e.g., evaluating a
driver after an automobile accident).
3. In detecting occult (secretive or hidden)
use of alcohol and other substances in
therapeutic settings where abstinence,
48
rehabilitation, and treatment are being

promoted.
Clinicians also can use the presentation of
information from biochemical markers to
patients as an effective tool in motivational
enhancement. For example, information
regarding liver transaminases (specific kinds
of enzymes that perform chemical reactions
within the liver) helps provide the patient
with objective information on the level of
recent alcohol use and potential acute hepatic
damage. This may help the patient move from
contemplating treatment to actually beginning
treatment. For a more detailed discussion of
biological markers in substance abuse, see
Javors and colleagues (1997).
Blood alcohol content

Blood alcohol content (BAC) can be determined
by highly sensitive laboratory procedures that
generally are available in most emergency
departments, hospitals, and clinical chemistry
laboratories. Alcohol elimination undergoes,
for the most part, zero-order kinetics (decreasing a set amount per unit of time rather than a
set percentage), so the concept of half-life is not
really accurate. However, first-order kinetics
and half-life do occur when BAC is low (i.e.,
below 10mg percent), and the half-life is on the
order of about 15 minutes at that point.
Though disappearance rates of 15mg percent
per hour are probably average for moderate
drinkers, higher values were seen in a group of
Swedish drivers apprehended for driving while
intoxicated (19mg/dL/hr) (Jones and Andersson
Chapter 4
Figure 4-1
Assessment Instruments for Dependence and Withdrawal From Alcohol
and Specific Illicit Drugs
Drug of Dependence
Instrument
Reference
Notes
Alcohol
CIWA-Ar
Sullivan et
al. 1989
10 items that take 2 to 5 minutes to complete; scores 067, with 10 or greater as

clinically significant; requires training to
administer
Cocaine
Cocaine Selective
Severity
Assessment (CSSA)
Kampman et
al. 1998
18 items that take 10 minutes to complete; high scores correlated with poor
outcome
Opioids
Subjective Opiate
Withdrawal Scale
(SOWS)
Handelsman
et al. 1987
16-item questionnaire; using a scale of

04, respondents rate to what extent
they are currently experiencing each of
16 characteristics; higher scores indicate
more severe withdrawal
Objective Opiate
Withdrawal Scale
(OOWS)
Handelsman
et al. 1987
Rater observes patient for about 10 minutes and indicates if any of 13 manifestations of withdrawal are present; scores
can range from 0 to 13, with higher
scores indicating more severe withdrawal; staff must be familiar with withdrawal signs
1996). The rate of metabolism of alcohol

increases with dependencesome alcoholics
can metabolize 2025mg/dL/hr (Jones and
Andersson 1996), and Jones and Sternebring
(1992) have found that alcohol-dependent
patients may metabolize 22mg/dL/hr during
detoxification.
When knowledge of BAC is combined with
clinical information, the healthcare provider
can make some predictions regarding the
acuteness of withdrawal. For example, in an
individual whose blood alcohol level is 200mg
percent but who is already showing tremulousness (shakiness of the hands), brisk
reflexes, tachycardia (rapid heart rate),
diaphoresis (excessive sweating), and perhaps
a CIWA-Ar score in the moderate or high
range (about 15 or higher), the clinician can

reasonably predict that the withdrawal will be
relatively severe. As noted, however, the rate
of metabolism of alcohol increases with
dependence. The diagnosis of alcohol intoxication is a clinical diagnosis and not based
simply on a BAC. A person with a BAC of
200mg percent could be in withdrawal, intoxicated (showing related signs and symptoms),
or showing no signs and symptoms of either
intoxication or withdrawal. A BAC above
100mg percent does not necessarily indicate
clinical intoxication. Like all laboratory procedures, the blood alcohol levels test has limitations. Usually, patient permission must be
obtained prior to testing, the testing itself can
be expensive, and forensic testing may be
subject to specific legal procedures.
Physical Detoxification Services for Withdrawal From Specific Substances
49
Reading Blood Alcohol Concentrations

Blood alcohol concentrations are measured in milligrams (mg) of alcohol per deciliter (dL) of blood. This
figure is converted to a percentage. One hundred mg/dL equals 100mg percent or 0.1 percent. Thus, a BAC
of .1mg percent is equivalent to a concentration of 100mg of alcohol per deciliter of blood.
Source: Center for Substance Abuse Treatment (CSAT) 1995a.
Breath alcohol levels

Although the initial cost of small breath alcohol
instruments may be relatively high, the recurring costs (of disposable mouthpieces and periodic recalibration) are low. The technique is
less invasive than blood testing and health
providers can follow breath alcohol levels
repeatedly at low expense during the course of
assessment and detoxification. The detection of
rapidly rising, high levels of alcohol over a
short period of time may indicate alcohol poisoning overdose. Breath alcohol levels provide
useful guidance in determining whether to hospitalize these patients.
Limitations on breath alcohol determinations
are that patient cooperation is required and
that some patients with lung diseases are not
able to muster a sufficient tidal volume (forceful breath) to give an accurate reading to the
machine. On occasion, patients whose breath
alcohol levels indicate recent alcohol use will
assert that they have recently gargled with
mouthwash that contained alcohol. Having the
patient rinse his mouth with water several
times and then making another breath alcohol
determination in 15 to 30 minutes usually will
resolve whether the patients assertion is valid.
50
chromatography, urine alcohol concentration,

and gas chromatography-mass spectrometry.
Informed clinicians also should be aware of
which drugs are screened for by the laboratory
they use, the relative time window of detection
(a substances metabolic half-life, or approximately how long a drug can be detected once
ingested), and whether cross-reactivity with
other interfering substances may alter outcomes. Many laboratories perform more specific confirmation testing on positive screening
tests, which can largely eliminate false-positives. It is important to clarify which type of
test result is being reported. Interfering and
cross-reactive substances leading to false-positive tests frequently are discussed in bulletins
and publications periodically published by the
National Institute on Drug Abuse (NIDA) and
the Centers for Disease Control and Prevention
(CDC). Usually, the senior laboratory supervisor has up-to-date information in this area and
often can be consulted via e-mail or telephone
in an emergency. Limitations of urine drug
screening include consent and privacy issues,
expense, the inability to screen for some drugs
of abuse, and the inability of urine drug
screens to provide information on the current
level of intoxication.
Urine drug screens
Urine testing should at a minimum test for the

presence of
Urine drug screens vary widely in their methods of detection, sensitivity and specificity,
expense, and availability. The healthcare
provider assessing patients for detoxification
should be familiar with the type of assay (test
measurement) being used; some examples are
enzyme multiple assay techniques, thin layer
chromatography, high performance liquid
Benzodiazepines
Barbiturates
Cocaine
Amphetamines
Opioids
PCP
Chapter 4
It also should be noted that current testing for

opioids primarily refers to organic drugs that
are derived from opium (i.e., heroin, codeine,
and morphine). Synthetic opioids like
hydrocodone and methadone are not detected
by the usual tests; this is true of oxycodone as
well. If the use of these drugs is suspected, special tests can be ordered. Most important, each
program should tailor its urine screening tests
to reflect the substance use patterns prevalent
in the community.
Gamma-glutamyltransferase
(GGT)
GGT has been measured in serum (the portion
of the blood that has neither red nor white
blood cells) for many years as a marker for
liver damage. More recently, GGT has been
advocated as a measure of cumulative alcohol
use (Dackis 2001). Sensitivity of the test is in
the 60 to 70 percent range and specificity (its
ability not to misidentify or confuse alcohol use
with other disorders) is in the 40 to 50 percent
range. In general, both sensitivity and specificity are lower in females than males. GGT does
correlate with alcohol intake but often requires
heavy drinking (more than six drinks per day)
to elevate it, and only about half of individuals
will show elevations. The half-life of elevated
serum GGT after the onset of abstinence is said
to be 2 to 3 weeks with alcoholic liver disease.
Chlorpromazine, phenobarbital, and
acetaminophen can all raise serum GGT levels.
GGT is limited by its expense and its relatively low specificity, which sometimes leads to
false-positive evaluations. GGT is helpful as a
motivational enhancer in patients with a high
degree of denial during detoxification.
Evidence of liver damage, as measured by the
GGT, provides patients with objective feedback concerning the consequences of their
alcohol use and thus plays a very important
role in enhancing motivation.
Hepatitis is a general term that refers to
inflammation of the liver with damage to liver
cells (hepatocytes). Hepatitis may be due to
viruses (such as in hepatitis A, B, C) or
insults to the liver from toxins (such as chemicals, alcohol, prescribed or over-the-counter
medications). In any form of hepatitis, GGT
may be elevated, indicating damage to liver
cells. Therefore, GGT elevation does not
automatically mean liver damage from alcohol
use, although this is certainly one of the most
common reasons for elevated GGT levels in
patients hospitalized in North America. The
use of GGT levels along with carbohydratedeficient transferrin (CDT) levels is a relatively sensitive and specific indicator of alcohol use. The CDT test is discussed below.
Carbohydrate-deficient
transferrin
CDT has been developed over the past 20 years
as a marker of cumulative alcohol consumption
but is just now becoming widely available as a
clinical tool. Sensitivities appear to be in the 70
to 80 percent range, and specificities of greater
than 90 percent have been found. Sensitivity
and specificity are somewhat lower among
females than males. Most therapeutic drugs or
drugs of abuse do not appear to affect CDT
levels. When CDT and GGT levels are combined, sensitivity and specificity rise to more
than 90 percent (Anton 2001). CDT testing is
limited by its relatively high cost, lack of clinical availability in some laboratories, and falsepositive results in abstaining individuals who
have endstage liver disease from causes other
than alcohol use (DiMartini et al. 2001).
Mean corpuscular
volume (MCV)
Erythrocyte (red blood cell) size is measured in
a Coulter counter and often is part of a complete blood count; therefore, it is widely available to clinicians. Sensitivity and specificity are
in the 30 to 50 percent range. Hence, caution
should be exercised when interpreting an elevated MCV in relation to drinking behavior.
This lab test should be considered complementary to other biological markers that are more
specific and sensitive, such as GGT or CDT.
Advanced age, nutritional status, cigarette
51
smoking, and co-occurring disease states without the presence of alcoholism may make test
results abnormal.
Alcohol Intoxication
and Withdrawal
Intoxication Signs and
Symptoms
52
in monitoring vital functions, protecting respiration, and observing aspiration, hypoglycemia, and thiamin deficiency. Screening for
other drugs that may contribute to the coma,
as well as other sources of coma induction,
should be done. Agitation is best managed with
interpersonal and nursing approaches rather
than additional medications, which may only
complicate and delay the elimination of the
alcohol.
The clinical presentation of intoxication from

alcohol varies widely depending in part on
blood alcohol level and level of previously
developed tolerance. At alcohol concentrations
between 20mg percent and 80mg percent, loss
of muscular coordination, changes in mood,
personality alteration, and [increases in motor
activity] begin. At levels from 80 to 200mg percent, more progressive neurologic impairment
occurs with ataxia (inability to coordinate muscular activity) and slurring of speech being
prominent. A variety of cognitive functions also
are impaired. At blood alcohol levels between
200 and 300mg percent nausea and vomiting
may occur, which along with sedation may
place patients at grave risk for aspiration of
stomach contents. At levels greater than 300mg
percent, hypothermia (low body temperature)
with impairment of level of consciousness is
likely except in all but the most tolerant individuals. Coma begins to be seen at levels of 400
to 600mg percent, but this is variable, again
depending on tolerance. Although exceptions
are found, BACs between 600 and 800mg percent are fatal. At this point, respiratory, cardiovascular, and body temperature controls
fail. See Figure 4-2 for more symptoms of alcohol intoxication.
Withdrawal Signs and

Symptoms
Since the elimination rate of alcohol from the

body generally is 10 to 30mg percent per hour,
the goals for the treatment of alcohol intoxication are to preserve respiration and cardiovascular function until alcohol levels fall into a
safe range. Patients who are severely intoxicated and comatose as the result of alcohol use
should be managed in the same manner as all
comatose patients, with particular care taken
Delusions, usually of paranoid or persecutory

varieties
Hippocrates, writing around 400 B.C., gave us

our first written clinical picture of alcohol withdrawal when he wrote that if the patient is in
the prime of life and if from drinking he has
trembling hands, it may well be the case that
the patient is showing withdrawal signs and
symptoms. To this day, alcohol withdrawal
remains underrecognized and undertreated.
The signs and symptoms of acute alcohol withdrawal generally start 6 to 24 hours after the
patient takes his last drink. Alcohol withdrawal
may begin when the patient still has significant
blood alcohol concentrations. The signs and
symptoms may include the following:
Restlessness, irritability, anxiety, agitation
Anorexia (lack of appetite), nausea, vomiting
Tremor (shakiness), elevated heart rate,
increased blood pressure
Insomnia, intense dreaming, nightmares
Poor concentration, impaired memory and
judgment
Increased sensitivity to sound, light, and tactile sensations
Hallucinations (auditory, visual, or tactile)
Grand mal seizures (grand mal seizures represent a severe, generalized, abnormal electrical discharge of the major portions of the
brain, resulting in loss of consciousness, brief
cessation of breathing, and muscle rigidity
followed by muscle jerking; a brief period of
Chapter 4
Figure 4-2
Symptoms of Alcohol Intoxication*
Blood Alcohol Level
Clinical Picture
20100mg percent
Mood and behavioral changes

Reduced coordination
Impairment of ability to drive a car or operate machinery
101200mg percent
Reduced coordination of most activities

Speech impairment
Trouble walking
General impairment of thinking and judgment
201300mg percent
Marked impairment of thinking, memory, and coordination

Marked reduction in level of alertness
Memory blackouts
Nausea and vomiting
301400mg percent
Worsening of above symptoms with reduction of body temperature and blood

pressure
Excessive sleepiness
Amnesia
401800mg percent
Difficulty waking the patient (coma)

Serious decreases in pulse, temperature, blood pressure, and rate of breathing
Urinary and bowel incontinence
Death
*Varies greatly with level of tolerance (chronic users of alcohol may show less effect at any given blood
alcohol level).
Source: Consensus Panelist Robert Malcolm, M.D.

sleep, awakening later with some mild to even
severe confusion, generally occurs)
Hyperthermia (high fever)
Delirium with disorientation with regard to
time, place, person, and situation; fluctuation in level of consciousness
For a discussion of seizures and delirium,
including delirium tremens, see below under
the heading Management of Delirium and

Seizures (p. 63).
Mild alcohol withdrawal generally consists of
anxiety, irritability, difficulty sleeping, and
decreased appetite. Severe alcohol withdrawal
usually is characterized by obvious trembling
of the hands and arms, sweating, elevation of
pulse (above 100) and blood pressure (greater
53
than 140/90), nausea (sometimes with vomiting), and hypersensitivity to noises (which seem
louder than usual) and light (which appears
brighter than usual). Brief periods of hearing
and seeing things that are not present (auditory
and visual hallucinations) also may occur. A
fever greater than 101 F also may be seen,
though care should be taken to determine
whether the fever is the result of an infection.
Seizures and true delirium tremens, as discussed elsewhere, represent the most extreme
forms of severe alcohol withdrawal. Moderate
alcohol withdrawal is defined more vaguely,
but represents some features of both mild and
severe withdrawal.
The course of these symptoms is extremely
variable. An individual may progress partially through some of the symptoms noted above
and then have a slow improvement. Other
individuals may have mild to moderate symptoms with almost abrupt resolution. Yet
another group may present with a grand mal
seizure or with hallucinations. Some people
with alcohol dependence, regardless of their
pattern of drinking or the extent of drinking,
appear to develop minor symptoms or show
no symptoms of withdrawal. Infrequent binge
drinkers seem less likely to have withdrawal
symptoms than individuals who are heavy
regular users of alcohol who then abruptly
cease their alcohol use, but this is not well
substantiated. As previously discussed in the
assessment section, the use of a standardized
clinical rating instrument for withdrawal such
as the CIWA-Ar is valuable because it guides
the clinician through multiple domains of
alcohol withdrawal and allows for semi-quantitative assessment of nausea, tremor, autonomic hyperactivity, anxiety, agitation, perceptual disturbances, headache, and disorientation. Age, general health, nutritional factors, and possible co-occurring medical or
psychiatric conditions all appear to play a
role in increasing the severity of the symptoms of alcohol withdrawal.
The most useful clinical factors to assess the
likelihood and the extent of a current withdrawal is the patients last withdrawal and
54
the number of previous withdrawals (treated

or untreated) experienced, with three or four
being a particularly significant number for
the appearance of severe withdrawal reactions unless adequate medical care is provided. This assumption that this phenomenon
will manifest itself, which has been referred
to as the kindling hypothesis, is well-established in the research literature (Booth and
Blow 1993; Wojnar et al. 1999).
Uncomplicated or mild to moderate withdrawal is characterized by restlessness, irritability, anorexia (lack of appetite), tremor
(shakiness), insomnia, impaired cognitive
functions, and mild perceptual changes.
Complicated or severe medical withdrawal
has one or more elements of delirium, hallucinations, delusions, seizures, and disturbances
of body temperature, pulse, and blood pressure.
Medical Complications of
Alcohol Withdrawal: Possible
Fatal Outcomes
Seizures; delirium tremens (severe delirium
with trembling); and dysregulation of body
temperature, pulse, and blood pressure are
outcomes in severe alcohol dependence that can
lead to fatal consequences. Other medical complications of alcohol withdrawal include infections, hypoglycemia, gastrointestinal (GI)
bleeding, undetected trauma, hepatic failure,
cardiomyopathy (dilation of the heart with
ineffective pumping), pancreatitis (inflammation of the pancreas), and encephalopathy
(generalized impaired brain functioning). The
suspicion of impending complications or their
appearance will require hospitalization of the
client and possible intensive care unit level of
management. Consultation with internists specializing in infectious disease, pulmonary care,
and hepatology; surgeons; neurologists; psychiatrists; anesthesiologists; and other specialists
also may be warranted, depending on the
nature of the complications.
Chapter 4
Management of Withdrawal
Without Medication
The management of an individual in alcohol
withdrawal without medication is a difficult
matter because the indications for this have not
been established firmly through scientific studies or any evidence-based methods.
Furthermore, the course of alcohol withdrawal
is unpredictable and currently available techniques of screening and assessment do not
allow us to predict with confidence who will or
will not experience life-threatening complications. Severe alcohol withdrawal may be associated with seizures due to relative impairment of
gamma-aminobutyric acid (GABA) and relative
over-activity of N-methyl-D-aspartate systems
(a subtype of the excitatory glutamate receptor
system) (Moak and Anton 1996). The failure to
treat incipient convulsions is a deviation from
the established general standard of care.
Positive aspects of the nonmedication
approach are that it is highly cost-effective
and provides inexpensive access to detoxification for individuals seeking aid. Observation
is generally better than no treatment, but
people in moderate to severe withdrawal will
be best served at a higher level of care. Young
individuals in good health, with no history of
previous withdrawal reactions, may be well
served by management of withdrawal without
medication. However, personnel supervising
in this setting should possess assessment abilities and be able to summon help through the
emergency medical system. Methods of withdrawal management without medication
include frequent interpersonal support, provision of adequate fluids and food, attention
to hygiene, adequate sleep, and the maintenance of a no-alcohol/no-drug environment.
Social Detoxification
Social detoxification programs are defined as
short-term, nonmedical treatment services for
individuals with substance use disorders. A
social detoxification program offers room,
board, and interpersonal support to intoxicated individuals and individuals in substance use
withdrawal. The consensus panel has found

that in actual practice, social detoxification
programs vary greatly in their approach and
scope. Some programs offer some medical and
nursing onsite supervision, while others provide access to medical
and nursing evaluation through clinics,
For alcohol,
urgent care programs, and emergensedative-hypnotic,
cy departments.
Some social detoxifiand opioid withcation programs only
offer basic room and
drawal syndromes,
board for a cold
turkey detoxificahospitalization (or
tion, while other programs offer supersome form of
vised use of medications. Sometimes
medications are pre24-hour medical
scribed at the onset of
withdrawal by healthcare) is generally the
care professionals in
an outpatient setting,
preferred setting for
while the staff in the
social detoxification
detoxification, based
program supervises
the administration of
on principles of
these medications.
Whatever the particsafety and humaniular situation might
be, there should
tarian concerns.
always be medical
surveillance, including monitoring of
vital signs, as part of every social detoxification
program.
The consensus panel agrees that for alcohol,
sedative-hypnotic, and opioid withdrawal syndromes, hospitalization (or some form of 24hour medical care) is generally the preferred
setting for detoxification, based on principles of
safety and humanitarian concerns. When hospitalization cannot be provided, a setting that
provides a high level of nursing and medical
backup 24 hours a day, 7 days a week is desirable. The panel readily acknowledges that
social detoxification programs are, for some
55
communities, the only available resources for

uninsured, homeless individuals. Social detoxification is preferable to detoxification in unsupervised settings such as the street, shelters, or
jails. The panel also notes that in some large
urban areas, social detoxification programs
have longstanding, excellent reputations of providing high-quality supervision and nurturance
for their clients.
Social detoxification
programs are orgaFor a substantial
nized and funded by
a variety of sources,
group of
including faith-based
organizations, comindividuals,
munity charities,
and municipal and
other local governsubstance use
ments.
withdrawal
The genesis of social

detoxification is
syndromes do not
complex. Often,
these programs grew
lead to fatal
out of community
needs when no other
alternatives were
outcomes or even
available. Early
reports (Whitfield et
significant
al. 1978) indicated
that many individumorbidity.
als in alcohol withdrawal could be
managed successfully without medications in a social detoxification
setting. Subsequent reviews that have revisited
the topic (Lapham et al. 1996) have reached
similar conclusions. Critical analysis of these
reports by the consensus panel indicates that
some of the scientific issues were oversimplified
and misleading. A number of these studies, in
fact, excluded many seriously ill clients from
their surveys prior to referral to social detoxification. Some of these surveys had a very high
staff-to-client ratio during social detoxification,
thus providing an unusually high level of psychological support. This level of staffing is not
frequently found today in social detoxification
programs.
56
The consensus panel acknowledges that, for a

substantial group of individuals, substance
use withdrawal syndromes do not lead to fatal
outcomes or even significant morbidity.
Determining which individuals will have
benign outcomes often is difficult, and in fact
this determination prior to social detoxification referral frequently is not made. Some
incorrect beliefs have sprung up in the context of social detoxification: Individuals
undergoing opioid withdrawal often are considered to require hospitalization to alleviate
suffering, while individuals undergoing alcohol withdrawal sometimes are, for a variety of
reasons, denied hospital-level treatment for
detoxification, even though alcohol withdrawal produces suffering and may have fatal consequences.
The consensus panel agreed on several guidelines for social detoxification programs:
Such programs should follow local governmental regulations regarding their licensing
and inspection.
It is highly desirable that individuals entering
social detoxification be assessed by primary
care practitioners (physicians, physician
assistants, nurse practitioners) with some
experience in substance abuse treatment.
Such an assessment should determine
whether the patient currently is intoxicated
and the degree of intoxication, the type of
withdrawal syndrome, severity of the withdrawal, information regarding past withdrawals, and the presence of co-occurring
psychiatric, medical, and surgical conditions
that might well require specialized care (see
chapter 3, Figure 3-1, p. 25).
Particular attention should be paid to those
individuals who have undergone multiple
withdrawals in the past and for whom each
withdrawal appears to be worse than previous onesthis is the so-called kindling
effect (Ballenger and Post 1978; Booth and
Blow 1993; Malcolm et al. 2000; Shaw et al.
1998; Wojnar et al. 1999; Worner 1996).
Subjects with a history of severe withdrawals, multiple withdrawals, delirium
Chapter 4
tremens, or seizures are not good candidates

for social detoxification programs.
All social detoxification programs should
have an alcohol- and drug-free environment,
have personnel who are familiar with the features of substance use withdrawal syndromes, have training in basic life support,
and have access to an emergency medical system that can provide transportation to emergency departments and other sites of clinical
care.
With Medications
Over the last 15 years several reviews and position papers (Fuller and Gordis 1994; Lejoyeux
et al. 1998; Mayo-Smith 1997; Nutt et al. 1989;
Shaw 1995) have asserted that only a minority
of patients with alcoholism will in fact go into
significant alcohol withdrawal requiring medications. Identifying that significant minority
sometimes is problematic, but there are signs
and symptoms of impending problems that can
alert the caretaker to seek medical attention.
Deciding on whether to use medical management for the treatment of alcohol withdrawal
requires that patients be separated into three
groups. The first and most obvious group
comprises those clients who have had a previous history of the most extreme forms of withdrawal, that of seizures and/or delirium. This
group is discussed in more detail below, but
in general, the medication treatment of this
group in early abstinence, whether or not
they have had the initiation of withdrawal
symptoms, should proceed as quickly as possible.
The second group of patients requiring immediate medication treatment includes those
patients who are already in withdrawal and
demonstrating moderate symptoms of withdrawal.
The third group of patients includes those
who may still be intoxicated and therefore
have not had time to develop withdrawal
symptoms or who have, at the time of admis-
sion, been abstinent for a few hours and have

not developed signs or symptoms of withdrawal. A decision regarding medication for this
group should be in part based on age, number of years of alcohol dependence, and the
number of previously treated or untreated
severe withdrawals (three or four appears to
be a significant threshold in predicting future
serious withdrawal) (Shaw 1995). If there is
an opportunity to observe the patient in the
emergency department of the clinic or similar
setting over the next 6 to 8 hours, then it is
possible to delay a decision regarding treatment and periodically reevaluate a client of
this category. If this is not possible, then the
return of the patient to a setting in which
there is some supervision by family, significant others, or in a social detoxification program is desirable.
The decision as to whether to give the patient
a single medication dose prior to discharge
and perhaps provide one or two additional
medication doses to be administered in the
referral setting rests on adequacy of supervision, the probability of whether the patient
will drink while undergoing treatment, and
whether the patient can or will return for
assessments the following day. In some circumstances, no treatment may be safer than
treatment with medication. Mayo-Smith
(1997) has shown that benzodiazepines confer
protection against alcohol withdrawal seizures
and thus patients with previous seizures
should be treated early. The same applies to
delirium. Both of these topics will be explored
in greater detail in the next section.
Extremely heavy drinking in the weeks prior
to complete cessation also predicts more
severe withdrawal (Lejoyeux et al. 1998), but
confirming such a history often is difficult.
A less accepted and more controversial position on the indications for medication treatment for alcohol withdrawal springs from
studies that attempt to measure oxidative
stress, which is the formation of oxidative
free radicals (chemicals that damage proteins), and stress hormones during alcohol
withdrawal (Dupont et al. 2000; Tsai et al.
57
1998). These studies have asserted that individuals who are undergoing mild withdrawal
without treatment still have the formation of
toxic oxidative products which have the hypothetical potential of producing neuronal damage and perhaps some cell death. Lending
support to this argument is the fact that alcohol withdrawal appears to be progressive in
that it worsens with each successive episode
(Malcolm et al. 2000) and that some patients
dependent on alcohol develop evidence of
dementia over time. On the other hand, age,
nutritional status, trauma, co-occurring conditions, and other unspecified events also
probably contribute to this process.
The decision to treat a patient in alcohol
withdrawal or at potential risk for alcohol
withdrawal will in great part rest on the clinical judgment of the practitioner, relying on
the factors noted above in addition to the
issue of whether treatment may in fact actually do more harm than good. This topic is discussed below under the heading Limitations
of Benzodiazepines in Outpatient Treatment
(p. 60). For more information about medication-assisted treatment, see TIP 43,
Medication-Assisted Treatment for Opioid
Addiction in Opioid Treatment Programs
(CSAT 2005d).
Benzodiazepine treatment of
alcohol withdrawal
Depending upon the clinical setting and the
patient circumstances, there are several acceptable regimens for treating alcohol withdrawal
that make use of benzodiazepines. These drugs
remain the medication class of choice for treating alcohol withdrawal. The early recognition
of alcohol withdrawal and prompt administration of a suitable benzodiazepine usually will
prevent the withdrawal reaction from proceeding to serious consequences. Patients suspected
of alcohol withdrawal should be seen promptly
by a primary care provider (physician, nurse
practitioner, physician assistant) who has experience in diagnosing and managing alcohol
withdrawal. Practitioners are reminded that
58
benzodiazepines have side effects and limitations. These limitations are far more prominent
when treating alcohol withdrawal in an outpatient setting.
Loading dose of a benzodiazepine

Medical or nursing administration of a slowly
metabolized benzodiazepine, frequently intravenously, but sometimes orally, may be carried
out every 1 to 2 hours until significant clinical
improvement occurs (such as reducing the
CIWA-Ar score to 10 or less) or the patient
becomes sedated (Sellers and Naranjo 1985).
Patients at grave risk for the most severe complications of alcohol withdrawal or who are
already experiencing severe withdrawal should
be hospitalized and can be treated with this
regimen. In general, patients with severe withdrawal may receive 20mg of diazepam or
100mg of chlordiazepoxide every 2 to 3 hours
until improvement or sedation prevails.
Oversedation, ataxia (lack of muscular coordination), and confusion, particularly in elderly
patients, may occur with this protocol. The
treatment staff should closely monitor hemodynamic (blood pressure and pulse) and respiratory features. They should particularly be prepared to detect and rapidly treat apnea (no
breathing) with assisted ventilation. Having
experienced staff with adequate time to frequently monitor the patient and provide intravenous medication is necessary.
Symptom-triggered therapy
Using the CIWA-Ar or similar alcohol withdrawal rating scales, medical personnel can be
trained to recognize signs and symptoms of
alcohol withdrawal, make a rating, and based
on that rating administer benzodiazepines to
their patients only when signs and symptoms
reach a particular threshold score. Studies
have demonstrated that appropriate training of
nurses in the application of the CIWA-Ar dramatically reduces the number of patients who
need to receive symptom-triggered medication
(Saitz et al. 1994; Wartenberg et al. 1990). This
regimen has been used successfully with short,
intermediate, and long half-life benzodiazepines.
Chapter 4
The training of staff in a standardized procedure of administering rating scales is important and periodic retraining to ensure continued reliability among raters is essential. A
typical routine of administration of symptomtriggered therapy is as follows: Administer
50mg of chlordiazepoxide (Librium) for
CIWA-Ar > 9 and reassess in 1 hour.
Continue administering 50mg chlordiazepoxide every hour until CIWA-Ar is < 10. Dosage
amount and frequency can be modified
depending on the individual clinical situation
as determined by the medical provider.
Patients with a history of withdrawal seizures
should receive scheduled doses of a long-acting benzodiazepine (e.g., diazepam [Valium],
20mg every 6 hours for 3 days) regardless of
CIWA-Ar score, and should receive additional doses if indicated by elevated CIWA-Ar
score. It must be noted here that symptomtriggered therapy is not recommended for
outpatient detoxification. Symptom-triggered
therapy requires monitoring and decisionmaking by a healthcare professional.
Gradual, tapering doses

Before beginning any tapering regimen, the
patient must be fully stabilized; that is, all signs
and symptoms of withdrawal must be
improved. Without proper stabilization, no
tapering scheme will succeed. Once the patient
has been stabilized, oral benzodiazepines can
be administered on a predetermined dosing
schedule for several days and gradually
tapered over time. This is a commonly used
regimen.
Dosing protocols vary widely among treatment facilities based on the needs of the
patient population. One example is that
patients might receive 50mg of chlordiazepoxide or 10mg of diazepam every 6 hours during
the first day of treatment and 25mg of chlordiazepoxide or 5mg of diazepam every 6
hours on the second and third days. This
approach to dosing, that is, every 6 hours, is
not as accurate in tailoring medications to
counter symptoms; a more precise dosing regimen is titrating (adjusting dosage in light of
drug response) according to severity of symptoms. An alternative regimen might be the

administration of 1 to 2mg lorazepam two or
three times a day the first day, followed by
gradual reduction over the next 3 to 5 days.
The general approach to tapering is to establish an acute dose in the first 24 hours, then
to reduce it over the next three days: for
example, 400 chlordiazepoxide total on day 1,
then 300, 200, 100,
and off on day 5.
This has to be
extended if
lorazepam is used.
Doses of withdrawal
Benzodiazepines
medication are omitted if the patient is
remain the
sleeping soundly,
showing signs of
medication class
oversedation, or
exhibiting marked
of choice for
ataxia.
treating alcohol
The use of gradual,
tapering doses is
appealing in settings
withdrawal.
where trained nursing or medical
observations cannot
be made frequently;
however, this in
itself is a pitfall.
Under- or overmedication with this regimen
can occur depending on benzodiazepine tolerance; the presence of chronic cigarette smoking, which induces benzodiazepine
metabolism; liver function; age; and the presence of co-occurring medical or psychiatric
conditions. The use of this regimen may be
problematic in the outpatient settings in
which it frequently is applied. Supplying the
patient with 4 to 5 days of a benzodiazepine
and facing the probability that the patient
may drink and take the benzodiazepine is a
hazard. It is important to enforce strict limitations on driving automobiles, climbing, or
operating hazardous machinery.
59
Single daily dosing protocol

Jauhar and Anderson (2000) compared single
daily dosing of diazepam to multiple daily dosing of chlordiazepoxide in inpatients being
treated for alcohol withdrawal. Patients in the
diazepam single daily dose group did as well as
the chlordiazepoxide multiple dosing group.
The authors suggest that this regimen might be
attractive in community or social detoxification
settings, particularly if patients could be monitored between administered doses. Further
study with a larger group of patients is needed.
The choice of the specific benzodiazepine for
any particular regimen depends on a number
of factors, but the most significant factor is that
the clinician administer one that she has the
most experience using. Despite 30 years of
research, no single benzodiazepine has emerged
as the number one drug of choice in treating
alcohol withdrawal. All benzodiazepines studied have worked better than placebo but have
been roughly equivalent with each other. Many
clinicians prefer long half-life benzodiazepines
such as chlordiazepoxide and diazepam, desiring less frequent daily dosing, relatively steady
serum levels, and the ability of these drugs to
self-taper based on their long half-lives.
Diazepam and chlordiazepoxide

Both diazepam and chlordiazepoxide have
excellent rapid oral absorption and are available for intravenous (IV) use. Intramuscular
use of these drugs is to be discouraged since
muscle absorption is erratic. One study suggests that if chlordiazepoxide (Librium) is
taken in overdose with alcohol, it is less likely
to be fatal than diazepam (Valium) (Serfaty
and Masterton 1993). Detractors of the use of
these two drugs point out that they have long
half-lives (although some clinicians see this as
an advantage because it prevents the emergence of withdrawal symptoms between doses),
have multiple active metabolites, and go
through many oxidative metabolic steps in the
liver. Older patients or patients with liver disease are likely to accumulate these medications
quickly without being able to metabolize them.
Possible consequences include oversedation or
60
ataxia, and on rare occasions, confusion may

ensue.
Lorazepam
Lorazepam (Ativan) has an intermediate halflife of about 815 hours, and although it usually is administered in multiple doses each day, it
can be given approximately twice per day.
Lorazepam, with its shorter half-life and lack
of storage in adipose (fatty) tissue, actually has
to be given more frequently than the long-acting preparations, not less. It is absorbed easily
orally, intramuscularly, and intravenously.
Older patients and patients with severe liver
disease tolerate it well and it is an effective
anticonvulsant in blocking a second alcohol
withdrawal seizure (DOnofrio et al. 1999).
However, it has been suggested that seizures
may occur late in detoxification with short-acting benzodiazepines such as lorazepam and
oxazepam (Shaw 1995).
Oxazepam
Oxazepam (Serax) often is favored by internists
and hepatologists treating alcohol withdrawal
in patients with severe liver failure. It has a relatively short half-life of 6 to 8 hours. Its
metabolism is very simple and it has no
metabolites. The agent is relatively limited in
that its oral absorption is quite slow compared
to other benzodiazepines, it must be given
three to four times a day, and is only available
in the United States in an oral form.
Ultimately, the experience of the treating clinician, characteristics of the patient, and the setting in which he will be treated will determine
the choice of drug. Although all benzodiazepines are now generic in the United States,
costs vary and this too may be a factor in
choice.
Limitations of benzodiazepines in
outpatient treatment
Although benzodiazepines remain the mainstay
of treatment for alcohol withdrawal, they have
limitations that are particularly pronounced
when treating outpatients. Benzodiazepines
potential interactions with alcohol can lead to
coma and respiratory suppression, motor incoChapter 4
ordination (leading to falls and automobile

accidents), and abuse of the medications.
Abuse usually is in the context of the concurrent use of alcohol, opioids, or stimulants.
There are two other limitations of benzodiazepines that may be relevant in some clinical
settings for some patients. First, although benzodiazepines have been studied for more than
30 years and are effective for suppressing alcohol withdrawal symptoms at any one episode,
their ability to halt the progressive worsening
of each successive alcohol withdrawal reaction
is in question. There are now at least nine studies that have found that an ever-increasing
number of previous alcohol withdrawals
increases the severity of withdrawal, particularly seizures and delirium tremens, and
decreases responsiveness to benzodiazepines
(Ballenger and Post 1978; Booth and Blow
1993; Brown et al. 1988; Gross et al. 1972;
Lechtenberg and Worner 1990, 1992; Malcolm
et al. 2000; Shaw et al. 1998; Worner 1996). A
tenth study (Wojnar et al. 1999) found that
increasing severity of alcohol withdrawal symptoms was observed only in a minority (22 percent) of 418 repeatedly treated clients.
However, within this group of one in five individuals, seizures were three times more common than in the larger, nonprogressive group
and premature age of death was 7 years
younger than for the nonprogressive group. In
the majority of these studies, patients were

treated with benzodiazepines, although in a
few, phenobarbital was used.
A second, and at present more hypothetical,
concern about benzodiazepine use to treat outpatients in alcohol withdrawal is that they may
prime or reinstate alcohol use during their
administration. Two preclinical studies support
this premise (Deutsch and Walton 1977;
Hedlund and Wahlstrom 1998). A recent randomized, blinded, clinical trial comparing carbamazepine to lorazepam for the outpatient
treatment of alcohol withdrawal found that the
outpatients on lorazepam were three times as
likely to drink as those on carbamazepine. The
lorazepam group drank about twice as much
alcohol in the immediate post-detoxification
period than the carbamazepine group (Malcolm
et al. 2002).
For a list of potential contraindications to using
benzodiazepines to treat alcohol withdrawal in
certain patients, see Figure 4-3.
Other medications
Barbiturates
Barbiturates have been used for nearly a century for the treatment of alcohol withdrawal.
Most barbiturates, other than phenobarbital,
have fallen into disfavor because of severe
Figure 4-3
Potential Contraindications To Using Benzodiazepines To Treat
Alcohol Withdrawal
Previous allergic reaction
Previous paradoxical disinhibition (e.g., violence, agitation, self-harm)
Previous serious adverse outcomes that could have medico-legal consequences if they re-occur (e.g.,
fractured hip, status epilepticus [continuous seizures of several minutes])
Severe alterations in mental status with low dose of benzodiazepines (e.g., confusion, delirium)
An outpatient setting where benzodiazepine use with alcohol has occurred previously with extreme intoxication leading to injuries, coma, or apnea
61
lethal interactions
with alcohol, death
Delirium and
from overdose of the
agents alone, rapid
seizures are the
tolerance, and high
abuse potential.
two most
Barbiturates are
highly addictive. In
pathological
clinical practice, the
medication is effective both for the
responses seen in
treatment of alcohol
withdrawal and
alcohol
sedative-hypnotic
withdrawal although
withdrawal.
few controlled trials
have been conducted with it (Wilbur
and Kulik 1981). Phenobarbital has a long
half-life and may rapidly accumulate.
Overdoses with phenobarbital also can be fatal.
Members of the consensus panel recommend its
use only in highly supervised settings.
Anticonvulsants
Anticonvulsants have been used in Europe for
a quarter of a century for the treatment of
alcohol withdrawal. Carbamazepine (Atretol,
Tegretol) has been shown in at least three trials
to be as effective as various benzodiazepines in
mild to moderate alcohol withdrawal (Malcolm
et al. 2001). Although less well studied, valproic acid also has been shown to be effective
(Reoux et al. 2001). Older, first-generation
anticonvulsants have limitations in that they
only have been studied in mild to moderate
withdrawal, can on rare occasions have serious
hepatic and bone marrow toxicities, interact
with several other classes of medication, and
are only available in oral forms. They are not,
however, controlled substances, are not
abused, and as previously noted, carbamazepine may have the propensity to reduce
some of the indices of drinking behavior immediately in the post-withdrawal treatment of outpatients. Newer drugs such as tiagabine, oxcarbazepine, and gabapentin do not appear to
have these liabilities, but sufficient studies have
not been done to confirm their effectiveness
and safety.
62
Other agents
Beta blockers and alpha adrenergic agonists
such as clonidine have been used in the treatment of alcohol withdrawal. They do not prevent seizures in delirium and have only modest
benefits for ameliorating symptoms of withdrawal. However, some patients will have
tachycardia (rapid heartbeat) and hypertension (high blood pressure) that will not be controlled by benzodiazepines, and beta blockers
and alpha adrenergic agonists can be of use in
these patients. Calcium channel antagonists will
also ameliorate some symptoms of alcohol withdrawal. As with beta blockers and clonidine,
calcium channel antagonists should be considered adjunctive therapy primarily to manage
extreme hypertension during withdrawal.
Antipsychotics
Antipsychotics have long been used to control
extreme agitation, hallucinations, delusions,
and delirium during alcohol withdrawal. Older,
low-potency drugs such as chlorpromazine generally are avoided since they can reduce the
seizure threshold. High-potency drugs such as
haloperidol (Haldol) also can reduce the
seizure threshold, but less commonly.
Haloperidol and related agents are available
for oral, intramuscular, and IV administration.
Clinicians should note that since antipsychotics
can lower the seizure threshold, their use during alcohol withdrawal should be undertaken
with great care and close supervision of the
patient is required.
Relapse prevention agents

Relapse prevention agents such as naltrexone
and acamprosate are under consideration as
additional therapies during late withdrawal
treatment, although they are not effective for
alcohol detoxification. Since one-third to onehalf of outpatients detoxifying with benzodiazepines will either drink or leave treatment
prematurely, naltrexone and acamprosate may
be valuable in assisting in reducing the probability of the individual drinking during late
detoxification. High-dose naltrexone therapy
has been associated with some liver toxicity,
but this has not been reported in individuals
taking therapeutic doses to enhance relapse
Chapter 4
prevention. Acamprosate may produce diarrhea and this may be already present in some
individuals in alcohol withdrawal. Thus far no
well-controlled studies have been conducted to
provide guidelines as to when these medications
should be introduced during detoxification or
whether it would be better to wait until the
early phase of rehabilitation. For an extended
review, see Kranzler and Jaffe (2003).
Other medications
Abecarnil (Anton et al. 1997), and more recently baclofen (Addolorato et al. 2002), have both
shown promise in the treatment of alcohol withdrawal. However, insufficient information has
been accumulated on these drugs, and therefore they are not recommended for use in clinical patient settings. Their use in alcohol withdrawal should be considered experimental and
premature for the present.
Management of Delirium and

Seizures
Delirium and seizures are the two most pathologic responses seen in alcohol withdrawal. The
major goal of medical management is to avoid
seizures and a special state of delirium called
delirium tremens (DTs) with aggressive use of
the primary detoxification drug (e.g., higher
doses of a benzodiazepine). Prevention is
essential where DTs are concerned. DTs do not
develop suddenly but instead progress from
earlier withdrawal symptoms. Properly administered symptom-triggered medication
approaches will prevent DTs and limit overmedication that can occur when high-dose benzodiazepines are administered without regard
to clinical response. It can be challenging clinically to differentiate impending DTs versus
benzodiazepine toxicity on day 3 of detoxification. When in doubt, in most cases it is safer to
overmedicate than to undertreat and allow DTs
to develop. Flumazenil (Romazicon) can be
used to reverse benzodiazepine overdose.
Death and disability may result from DTs or
seizures without medical care. Several factors
are related to severity of alcohol withdrawal:
high amounts of alcohol being consumed in the
weeks prior to treatment, the severity of the

last withdrawal episodes, and the number of
previously treated or untreated withdrawal
episodes. Other factors such as increasing age;
the patients general health, including nutritional status; the presence of co-occurring medical, surgical, and psychiatric disorders; and
the use of medications (prescription, over-thecounter, or herbal) also can amplify severity of
withdrawal symptoms. Early proper medical
management of alcohol withdrawal reduces the
probability of these complications, assuming
early recognition.
For patients with a history of DTs or seizures,
early benzodiazepine treatment is indicated at
the first clinical contact setting (e.g., doctors
office, clinic, urgent care, emergency department). Patients with severe withdrawal symptoms, multiple past detoxifications (more than
three), and co-occurring unstable medical and
psychiatric conditions should be managed similarly.
Once an initial clinical screening and assessment have been made, and the diagnosis is reasonably certain, medication should be given.
Giving the patient a benzodiazepine should not
be delayed by waiting for the return of laboratory studies, transportation problems, or the
availability of a hospital bed. Early thiamine
and multivitamin administration also should be
done at this time. Once full DTs have developed, they tend to run their course despite
medication management, and there is little evidence in the medical literature to suggest that
any medication treatment can immediately
abort DTs.
Patients presenting in severe DTs should have
emergency medical transport to a qualified
emergency department and generally will
require hospitalization. If the DTs are severe,
patients may need to be placed in an intensive
care unit (ICU), and in such settings continuous monitoring of cardiac rhythm, pulse, blood
pressure, oxygen saturation, temperature, and
respiration rates begins with the emergency
medical system and continues in the emergency
department and ICU.
63
Early care will depend on medical and surgical

complications and may involve protocols from
advanced cardiac life support (ACLS) and/or
advanced trauma life support. Correction of
fluids and electrolytes (salts in the blood),
hyperthermia (high fever), and hypertension
are vital. Loading doses (rapid administration
of initial high doses) of IV diazepam or
lorazepam are recommended, as are IV thiamine (prior to IV glucose) and multiple vitamins. The physician should consider intramuscular or intravenous haloperidol (Haldol and
others) to treat agitation and hallucinations.
Nursing care is vital, with particular attention
to medication administration, patient comfort,
soft restraints, and frequent contact with orienting responses and clarification of environmental misperceptions.
Alcohol withdrawal seizures represent another
management challenge (Ahmed et al. 2000),
since no large-scale clinical studies have been
conducted to establish firmly best treatment
practices. The majority of alcohol withdrawal
seizures occur within the first 48 hours after
cessation or reduction of alcohol, with peak
incidence around 24 hours (Victor and Adams
1953). Most alcohol withdrawal seizures are
singular, but if more than one occurs they tend
to be within several hours of each other. While
alcohol withdrawal seizures can occur several
days out, a higher index of suspicion for other
causes is prudent. Someone experiencing an
alcohol withdrawal seizure is at greater risk for
progressing to DTs, whereas it is extremely
unlikely that a patient already in DTs will also
then experience a seizure.
The occurrence of an alcohol withdrawal
seizure happens quickly, usually without warning to the individual experiencing the seizure or
anyone around him. The patient loses consciousness, and if seated usually slumps over,
but if standing will immediately fall to the floor.
The patients body is rigid, and breathing ceases. This part of the seizure is called the tonic
phase, which usually lasts for a few seconds
and rarely more than a minute.
The next part of the seizure (more dramatic
and generally remembered by witnesses) con64
sists of jerking of head, neck, arms, and legs.

Breathing resumes during this clonic phase of
the seizure but may be irregular. During the
clonic phase, the lips, tongue, or inside of the
cheeks may be bitten. Involuntary urination or
a bowel movement may occur. Immediately
after the jerking ceases, the patient generally
has a period of what appears to be sleep with
more regular breathing. Vomiting may occur at
this time. The period of sleep may be a few seconds with awakening or a few minutes. Rarely,
the patient may appear not to waken at all and
have a second period of rigidity followed by
muscle jerking. This is known as status epilepticus. Upon awakening, the individual usually
is mildly confused as to what has happened and
may be disoriented as to where she or he is.
This period of post-seizure confusion generally
lasts only for a few minutes but may persist for
several hours in some patients. Headache,
sleepiness, nausea, and sore muscles may persist in some individuals for a few hours. See the
text box on the next page for what to do in the
event of a seizure.
Patients who start to retch or vomit should be
gently placed on their side so that the vomitus
(stomach contents vomited) may exit the mouth
and not be taken into the lungs. Vomitus taken
into the lungs is a severe medical condition
leading to immediate difficulty breathing and,
within hours, severe pneumonia.
Predicting who will have a seizure during alcohol withdrawal cannot be accomplished with
any great certainty. There are some factors
that clearly increase the risk of a seizure, but
even in individuals with all of these factors,
most patients will not have a seizure. Out of
100 people experiencing alcohol withdrawal
only two or three of them will have a seizure.
The best single predictor of a future alcohol
withdrawal seizure is a previous alcohol withdrawal seizure. Individuals who have had three
or more documented withdrawal episodes in
the past are much more likely to have a seizure
regardless of other factors including age, gender, or overall medical health. However, certain other factors may increase the risk of
seizures for all patients:
Chapter 4
What To Do in the Event of a Seizure

At the first sign of what appears to be a seizure, lay witnesses should summon trained medical personnel.
Depending on the setting, this may mean calling 911 or calling the nurse or physician who is on duty for
the clinic or hospital unit.
While awaiting medical help, a layperson witnessing an alcohol withdrawal seizure should gently attempt
to prevent injury to the person as he or she slumps or falls to the floor by protecting the individuals head
and body from hard or sharp objects. Often, though, the initial loss of consciousness and fall is not seen
by anyone.
In the jerking phase of the seizure, if the jerking is extreme, it is important to protect the head from
extreme head-banging by placing a soft object under the head and neck. Sometimes placing ones hand or
shoe under the head is adequate.
No attempt should be made to insert anything in the mouth (such as spoons, pencils, pens, tongue blades).
Such attempts at object insertion may cause damage to the teeth and tongue, or objects may get partially
swallowed and obstruct the airway.
Patients who start to retch or vomit should be gently placed on their side so that the vomitus (stomach
contents vomited) may exit the mouth and not be taken into the lungs. Vomitus taken into the lungs is a
severe medical condition leading to immediate difficulty breathing and, within hours, severe pneumonia.
Even if the individual appears to become fully awake, alert, and oriented without any harm following a
seizure, it is strongly recommended that he be referred for medical evaluation.
Individuals who awaken confused and disoriented should be given brief reassuring and soothing messages
to reorient them as to what happened and where they are.
Having drunk for more than two decades
Having poor general medical health and poor
nutritional status
Having had previous head injuries
Having had disturbances of serum calcium,
sodium, potassium, or magnesium
Patients having a witnessed seizure can be
treated with IV diazepam or lorazepam and
ACLS protocol procedures. This reduces but
does not completely prevent the likelihood of a
second seizure (DOnofrio et al. 1999). In the
rare patient with recurrent multiple seizures or
status epilepticus (continuous seizures of several minutes) an anesthesiology consultation may
be required for general anesthesia. Evaluation
of electrolyte disturbances, central nervous system (CNS) trauma, and consideration of sedative-hypnotic withdrawal should be reviewed.
Patients who have had a single witnessed or
suspected alcohol withdrawal seizure should
be immediately given a benzodiazepine,
preferably with IV administration. The study

by DOnofrio and colleagues (1999) indicated
that a single dose of 1mg of IV lorazepam
reduced recurrent seizure risk, reduced rates
of return to emergency departments, and lowered hospitalization rates. Despite this
report, the consensus panel agrees that hospitalization for further detoxification treatment
is strongly advised to monitor and ameliorate
other withdrawal symptoms, reduce suffering,
and stabilize the patient for rehabilitation
treatment.
The addition of anti-epileptic drugs (AEDs)
has not been established as effective (Chance
1991; Hillbom and Hjelm-Jager 1984; Rathlev
et al. 1994). This is primarily based on evaluations of phenytoin (Dilantin and others).
Newer AEDs have not been studied extensively for preventing alcohol withdrawal seizures.
The consensus panel suggests that AED therapy should be considered in alcohol withdrawal patients with multiple past seizures (of any
cause), a history of recent head injury, past
65
meningitis, encephalitis, or family history of

seizures. Further evaluation of a first seizure
often warrants neurologic evaluation (computerized tomography and electroencephalogram), even if the seizure may be suspected to
have been due to alcohol withdrawal.
Patient Care and Comfort

Interpersonal support and hygienic care along
with adequate nutrition should be provided.
Staff assisting patients in detoxification should
provide whatever assistance is necessary to
help get patients cleaned up after entering the
facility and bathed thoroughly as soon as they
have been medically stabilized. Attention to the
treatment of scabies, body lice, and other skin
conditions should be given. Screening for
tuberculosis should be done. Dental and oral
care should be made available. The patient
should be screened for physical trauma,
including bruises and lacerations. Tetanus
immunization may be necessary. Patients with
an altered mental status or altered level of consciousness should be seen in emergency departments, evaluated, and possibly hospitalized.
Staff should continue to observe patients for
head injuries after admission because some
head injuries, such as subdural hematomas,
may not immediately be evident and cost considerations may preclude obtaining a brain
scan in some settings.
Other Immediate Concerns

Alcohol may interact with several classes of
medicine to produce serious CNS depression.
Some examples include benzodiazepines, barbiturates, meprobamate, and other sedative hypnotic groups. Metoclopramide and sedating
antipsychotic medicines such as phenothiazines
also can produce CNS suppression. A disulfiram-like (Antabuse) reaction characterized by
flushing, sweating, tachycardia, nausea, and
chest pain has been reported for metronidazole
and several antibiotics including, but not limited to, cefamandole, cefoperazone, and cefotetan. Acetaminophen in low doses may act
acutely with alcohol to produce hepatotoxicity
(liver damage). Clinicians also should deter66
mine whether the patient is using aspirin or

nonsteroidal anti-inflammatory medications
(for example, Motrin or Advil, both containing
ibuprofen) in conjunction with alcohol use.
Antidiabetic agents in concert with alcohol may
produce hypoglycemia (low blood sugar) and
lactic acidosis (blood that has become too
acidic). The therapeutic efficacy and margin of
safety for the use of anti-anxiety medications,
antidepressants, and antipsychotic medication
is thought by some to be lessened by alcohol
use, but this is based largely on anecdotal
information. Alcohol interacts with numerous
other classes of medications that lead to less
serious results. Some important examples are
sedatives, tranquilizers, antiseizure medications, and anticoagulants (blood thinners) such
as Coumadin. Patients who may be taking such
medications need to be carefully observed and
have their medications carefully monitored.
Opioids
Opioids are highly addicting, and their chronic
use leads to withdrawal symptoms that,
although not medically dangerous, can be highly unpleasant and produce intense discomfort.
All opioids (e.g., heroin, morphine, hydromorphone, oxycodone, codeine, and methadone)
produce similar effects by interacting with
endogenous (produced by the body itself) opioid (:, *, and 6) receptors (that is, specific sites
on cells where these substances bind to the
cell). Opioid agonists stimulate these receptors
and opioid antagonists block them, preventing
their action.
Opioid Withdrawal Symptoms

All opioid agents produce similar withdrawal
signs and symptoms with some variance in
severity, time of onset, and duration of symptomatology, depending on the agent used, the
duration of use, the daily dose, and the interval
between doses. For instance, heroin withdrawal
typically begins 8 to 12 hours after the last
heroin dose and subsides within a period of 3
to 5 days. Methadone withdrawal typically
begins 36 to 48 hours after the last dose, peaks
Chapter 4
after about 3 days, and gradually subsides over

a period of 3 weeks or longer. Physiological,
genetic, and psychological factors can significantly affect intoxication and withdrawal severity. Figure 4-4 summarizes many of the common signs and symptoms of opioid intoxication
and withdrawal.
The clinician uses intoxication and withdrawal measures as guides to avoid under- or overmedicating patients during medically supervised detoxification; the number and intensity
of signs determine the severity of opioid withdrawal. It is important to appreciate that
untreated opioid withdrawal gradually builds
in severity of signs and symptoms and then
diminishes in a self-limited manner. Repeated
assessments should be made during detoxification to determine whether symptoms are
improving or worsening. Repeated assessments also should address the effectiveness of
pharmacological interventions. Detoxification
strategies should aim to establish control over
the opioid withdrawal syndrome, after which

dose reductions can be made gradually.
Medical complications associated with opioid
withdrawal can develop and should be quickly identified and treated. Unlike alcohol and
sedative withdrawal, uncomplicated opioid
withdrawal is not life-threatening. Rarely,
severe gastrointestinal symptoms produced by
opioid withdrawal, such as vomiting or diarrhea, can lead to dehydration or electrolyte
imbalance. Most individuals can be treated
with oral fluids, especially fluids containing
electrolytes, and some might require intravenous therapies. In addition, underlying
cardiac illness could be made worse in the
presence of the autonomic arousal (increased
blood pressure, increased pulse, sweating)
that is characteristic of opioid withdrawal.
Fever may be present during opioid withdrawal and typically will respond to detoxification. Other causes of fever should be evaluated, particularly with intravenous users,
Figure 4-4
Signs and Symptoms of Opioid Intoxication and Withdrawal
Opioid Intoxication
Opioid Withdrawal
Signs
Bradycardia (slow pulse)
Hypotension (low blood pressure)
Hypothermia (low body temperature)
Sedation
Meiosis (pinpoint pupils)
Hypokinesis (slowed movement)
Slurred speech
Head nodding
Signs
Tachycardia (fast pulse)
Hypertension (high blood pressure)
Hyperthermia (high body temperature)
Insomnia
Mydriasis (enlarged pupils)
Hyperreflexia (abnormally heightened reflexes)
Diaphoresis (sweating)
Piloerection (gooseflesh)
Increased respiratory rate
Lacrimation (tearing), yawning
Rhinorrhea (runny nose)
Muscle spasms
Symptoms
Euphoria
Analgesia (pain-killing effects)
Calmness
Symptoms
Abdominal cramps, nausea, vomiting, diarrhea
Bone and muscle pain
Anxiety
Source: Consensus Panelist Charles Dackis, M.D.

67
because HIV infection, viral hepatitis, abscesses,

Methadone is the
infected injection
sites, and pneumomost frequently
nia occur commonly in this populaused agent
tion and always
require medical
approved for
attention. Anxiety
disorders, especially those involving
detoxification by
panic anxiety, also
might show
the FDA, and a
increased intensity
during opioid withnew medication,
drawal. Finally,
any condition
buprenorphine,
involving pain is
likely to worsen
has been
during opioid withdrawal because of a
approved for use.
reduced pain
threshold and the
lack of analgesia
(pain relief) afforded by opioid use.
This phenomenon is particularly common
with dental pain and chronic back pain.
Without Medications
It is not recommended that clinicians attempt
to manage significant opioid withdrawal symptoms (causing discomfort and lasting several
hours) without the effective detoxification
agents discussed below. Even mild levels of opioid use commonly produce uncomfortable levels of withdrawal symptomatology.
Management of this syndrome without medications can produce needless suffering in a population that tends to have limited tolerance for
physical pain.
68
With Medications
The management of opioid withdrawal with
medications is most commonly achieved
through the use of methadone (in addition to
adjunctive medications for nausea, vomiting,
diarrhea, and stomach cramps). Federal regulations restrict the use of methadone for opioid
withdrawal to specially licensed programs,
except in cases where the patient is hospitalized
for treatment of another acute medical condition. Methadone is the most frequently used
agent approved for detoxification by the Food
and Drug Administration (FDA), and a new
medication, buprenorphine (discussed below),
has been approved for use. Methadone can be
used for detoxification from heroin and all opioid agonists.
Another commonly used agent is clonidine
(Gold et al. 1984), an -adrenergic agonist
that relieves most opioid withdrawal symptoms without producing opioid intoxication or
drug reward. However, since clonidine detoxification is less effective against many opioid
withdrawal symptoms, adjunctive medicines
often are necessary to treat insomnia, muscle
pain, bone pain, and headache. Adjunctive
agents should not be used in the place of an
adequate detoxification dosage. Additional
opioid agonists could be used theoretically for
detoxification but would have to be administered off label, because the FDA has
approved only methadone for this purpose.
Off-label use (prescribing an agent approved
for another condition) could be difficult to
justify, given the efficacy of methadone in
reversing opioid withdrawal.
Detoxification is indicated for treatment-seeking persons who display signs and symptoms
sufficient to warrant treatment with medications and for whom maintenance is declined
or for some reason is not indicated or practical. In addition, individuals dependent on
opioids sometimes are hospitalized for other
health problems and may require hospitalbased detoxification even though they are not
Chapter 4
seeking substance abuse treatment. Such

patients also can be maintained on methadone
during the course of hospitalization for any
condition other than opioid addiction. The
hospital does not have to be a registered opioid treatment program, as long as the patient
was admitted for a detoxification treatment
for some substance other than opioids. On
the other hand, some persons may not have
used sufficient amounts of opioids to develop
withdrawal symptoms, and for others sufficient time may have elapsed since their last
dose to extinguish withdrawal and eliminate
the need for detoxification.
Methadone
This section discusses methadone as an agent
for detoxification. For detailed information
on methadone maintenance, readers are
referred to TIP 43 Medication-Assisted
Treatment for Opioid Addiction in Opioid
Treatment Programs (CSAT 2005d). While
methadone is one of the more common medications for opioid detoxification, its use is
highly regulated and it can only be prescribed
for withdrawal by a doctor at a Substance
Administration (SAMHSA)-certified
methadone clinic or if the patient is being
hospitalized for another medical condition.
(Detoxification programs may become certified to prescribe methadone by undergoing
the process described in TIP 43.) Federal regulations allow for the use of methadone in
both a short-term detoxification treatment of
less than 30 days and a long-term treatment
of 30 to 180 days. The regulations also specify
that if a patient has failed two detoxification
attempts in a 12-month period he or she must
be evaluated for a different course of treatment (e.g., ongoing opioid substitution
therapy).
Methadone is a long-acting agonist at the :-opioid receptor site that, in effect, displaces heroin (or other abused opioids) and restabilizes the
site, thereby reversing opioid withdrawal symptoms. If maintained for long enough, this stabilizing effect can even reverse the immunologic
and endocrinologic defects caused by long-term

heroin addiction. This is one of many important reasons to consider conversion to maintenance during most methadone detoxification
admissions.
Once the dose requirement for methadone has
been established, methadone can be given
once daily and generally tapered over 3 to 5
days in 5 to 10mg daily reductions. The initial
dose requirement is determined by estimating
the amount of opioid use and gauging the
patients response to administered
methadone. Clinicians should take care not to
underdose patients with methadone; adequate
dosage is vitally important. Patients sometimes exaggerate their daily consumption to
receive greater dosages of methadone. For
this reason, history is no substitute for a
physical examination that screens for signs of
opioid withdrawal. Treating clinicians should
not only be familiar with the intoxication and
withdrawal signs that are set forth in Figure
4-4 (p. 67), but also should be skilled in discerning these features of opioid withdrawal.
Avoidance of overmedicating is crucial during
methadone detoxification because excessive
doses of this agent can produce overdose,
whereas opioid withdrawal does not constitute
a medical danger in otherwise healthy adults.
For more information on methadone and
other medications used to treat opioid addiction, see TIP 43, Medication-Assisted
Treatment for Opioid Addiction in Opioid
Treatment Programs (CSAT 2005d).
Patients with significant opioid dependence
may require a starting dose of 30 to 40mg per
day; this dose range should be adequate for
even the most severe withdrawal. If the
degree of dependence is unclear, withdrawal
signs and symptoms can be reassessed 1 to 2
hours after giving a dose of 10mg of
methadone. The practice of giving a dose of
methadone and later assessing its effect (also
termed a challenge dose) is an important
intervention of detoxification. Sedation or
intoxication signs after a methadone challenge
dose indicate a lower starting dose. Similarly,
intoxication at any point of the detoxification
69
signals the need to hold or more rapidly wean

(reduce to a zero dose) the methadone. Care
should be taken to avoid giving methadone to
newly admitted patients with signs of opioid
intoxication, since overdose could result.
Note that methadone stabilization is the treatment of choice for patients who are pregnant
and opioid dependent.
muscle aches, and drug craving. Completion

rates for opioid detoxification using clonidine
have been low (ranging from 20 to 40 percent); those patients who complete the procedure are more likely to be dependent on opioids other than heroin, have private health
insurance, and report lower levels of subjective withdrawal symptoms than those who do
not complete (Strobbe et al. 2003).
Clonidine (Catapres)
An appropriate protocol for clonidine is

0.1mg administered orally as a test dose. A
dose of 0.2mg might be used initially for
patients with severe signs of opioid withdrawal or for those patients weighing more than
200 pounds. The sublingual (under the
tongue) route of administration also may be
used. Clinicians should check the patients
blood pressure prior to clonidine administration and clonidine should be withheld if systolic blood pressure is lower than 90 or diastolic blood pressure is below 60. These
parameters can be relaxed to 80/50 in some
cases if the patient continues to complain of
withdrawal and is not experiencing symptoms
of orthostatic hypotension (a sudden drop in
blood pressure caused by standing).
Clonidine (0.1 to 0.2mg orally) can then be
given every 4 to 6 hours on an as-needed
basis. Clonidine detoxification is best conducted in an inpatient setting, as vital signs
and side effects can be monitored more closely in this environment. In cases of severe
withdrawal, a standing dose (given at regular
intervals rather than purely as needed) of
clonidine might be advantageous (Alling
1992). The daily clonidine requirement is
established by tabulating the total amount
administered in the first 24 hours, and dividing this into a three or four times per day
dosing schedule. Total clonidine should not
exceed 1.2mg the first 24 hours and 2.0mg
after that, with doses being held in accordance with parameters noted above. The
standing dose is then weaned over several
days. Clonidine must be tapered to avoid
rebound hypertensions.
Clonidine was originally marketed and

approved for the treatment of high blood pressure but also has been used for opioid detoxification since 1978. While clonidine is not FDA
approved for treatment of opioid withdrawal, it
is widely used off label for this purpose
(Alling 1992) because the research literature
substantiates its effectiveness for this condition.
Advantages of clonidine over methadone in the
treatment of opioid withdrawal are as follows:
Clonidine does not produce opioid intoxication and is not reinforcing.
The FDA does not classify clonidine as having
abuse potential. Yet some abuse has been
reported. (See p. 107 under the section on
pregnant women and opioids.)
Since clonidine does not interact with the
:-opioid receptor, detoxification occurs
without opioids.
No special licensing is required for the dispensing of this medication.
One disadvantage to methadone detoxification
with naltrexone (an opioid antagonist), compared with clonidine, is that naltrexone, when
it is prescribed for abstinence, can precipitate
opioid withdrawal if given too soon after the
last methadone dose. This problem does not
exist with clonidine, making this agent particularly beneficial in a drug-free treatment program or a therapeutic community.
Nevertheless, patients addicted to opioids
generally prefer methadone over clonidine
detoxification. Although clonidine alleviates
some symptoms of opioid withdrawal, it usually is relatively ineffective for insomnia,
70
The clonidine transdermal (administered

through the skin) patch, FDA approved in
Chapter 4
1986 for the treatment of hypertension (high

blood pressure), also is used in opioid detoxification. However, the safety of the patch for
treatment of opioid withdrawal has not been
sufficiently studied in controlled clinical trials. The transdermal route of administration
has the disadvantage of continued clonidine
action even after the patch has been removed.
Blood pressure effects of clonidine can therefore be prolonged, leading to undesirable and
persistent reductions of blood pressure. For
this reason, it has been recommended that the
patch be used only if the patients blood pressure is monitored regularly (Alling 1992).
The clonidine patch is available in three
sizes that deliver a total daily oral equivalent
clonidine dose of 0.2mg (3.5 cm2), 0.4mg (7.0
cm2), or 0.6mg (10.5 cm2). The patch supplies
clonidine for up to 7 days and one patch
application usually is sufficient. The convenience of one application allows the clinician
to avoid the disruption that multiple dosing
might have during rehabilitative programming. In particular, patients can focus on
rehabilitative treatment without being distracted by the need to ask repeatedly for oral
clonidine doses. Vital signs should be monitored at least four times daily to assess persistent signs and symptoms of withdrawal or
undesirable effects of clonidine on blood pressure.
Buprenorphine
Buprenorphine, a partial -opioid agonist that
is FDA approved in an injectable form
(Buprenex) for the treatment of pain, has
recently been approved as a detoxification
agent and for opioid maintenance treatment as
an alternative to methadone maintenance. A
number of clinical trials have reported it to be
effective for heroin detoxification (Becker et al.
2001; Bickel et al. 1988; Diamant et al. 1998),
and the medication should play an important
role in gradually removing patients from
methadone maintenance (Amass et al. 2004;
Banys et al. 1994; Johnson et al. 2000).
Buprenorphine is available in oral form as

Subutex, which contains only buprenorphine,
and is meant for patients who are starting
treatment for drug dependence. Another
form, Suboxone, contains buprenorphine and
naloxone and is intended for persons dependent on opioids who have already started and
are continuing medication therapy.
Buprenorphine has great affinity for the
:-opioid receptor, in
spite of being only a
partial agonist, and
can displace other
One advantage of
opioids such as heroin. This feature gives
buprenorphine is
buprenorphine the
ability to precipitate
that it can be
opioid withdrawal
when administered to
dispensed at a
patients who have
recently used heroin
physicians office,
(Kosten and
McCance-Katz 1995).
unlike methadone,
An advantage to
buprenorphine is its
which can be
safety. Because of
the partial agonist
dispensed only at
action, buprenorphine has a ceiling
designated treateffect with regard to
overdose potential
ment centers.
(Walsh et al. 1994).
That is, unlike
methadone, which
produces increasing
respiratory suppression with increasing dose,
respiratory effects of buprenorphine tend to
level off due to its partial agonist action.
Another advantage of buprenorphine is that
it can be dispensed at a physicians office,
unlike methadone, which can be dispensed
only at designated treatment centers. This
makes access to this medication for opioid
dependence much more convenient for both
patient and clinician. See TIP 40, Clinical
Guidelines for the Use of Buprenorphine in
the Treatment of Opioid Addiction (CSAT
2004a).
71
Unlike methadone, buprenorphine may be

prescribed by physicians who are not connected with a certified opioid treatment program. However, there is a still a specific
training and certification process
physicians must
Inpatient
undergo in order to
prescribe the meditreatment can
cation. Information
on the legal aspects
provide additional
of prescribing
buprenorphine and
support, medical
rules for carrying
out detoxification in
the physicians
supervision, and
office can be found
at www.buprenorrehabilitative
phine.samhsa.gov/.
Information given
treatment that
at the site includes
the following on the
serve as
Drug Addiction
Treatment Act
disincentives to
(DATA) of 2000:
[DATA 2000]
relapse.
expands the clinical
context of medication-assisted opioid
addiction treatment by allowing qualified
physicians to dispense or prescribe specifically approved Schedule III, IV, and V narcotic
medications for the treatment of opioid addiction in treatment settings other than the traditional Opioid Treatment Program (i.e.,
methadone clinic). In addition, DATA 2000
reduces the regulatory burden on physicians
who choose to practice opioid addiction therapy by permitting qualified physicians to
apply for and receive waivers of the special
registration requirements defined in the
Controlled Substances Act (SAMHSA 2002).
Terminating Methadone
Maintenance Treatment
Individuals seeking the discontinuation of
methadone maintenance require a much more
lengthy detoxification process than that
72
described above for heroin. The methadone

dose should be tapered gradually by 5 to
10mg/week until a daily dose of 30 to 40mg has
been attained. At that time, detoxification with
either clonidine or smaller doses of methadone
can be instituted. The use of clonidine has the
advantage of brevity as a complete clonidine
detoxification usually can be conducted within
2 to 3 weeks (Gold et al. 1984).
Once the daily dose requirement has been
established by using the principles outlined
above, the patient can be placed on a standing dose of clonidine. The dose required usually is in the range of 0.2mg, three to four
times daily, although titration (adjustment of
dosage in light of drug response) is necessary
based on the information gathered during the
clinical examination. Additional doses as
needed (sometimes abbreviated PRN) of
0.2mg clonidine also can be given and blood
pressure parameters must be followed prior
to the administration of standing and PRN
doses to avoid orthostatic hypotension. The
initial standing dose can be reduced to 0.1mg,
given three to four times daily, after one week
of detoxification, with PRN doses of 0.1mg
available. After a period of 1 week on this
reduced dosage, clonidine is given for an
additional week only if needed. Because clonidine does not reverse all opioid withdrawal
symptoms, especially insomnia, adjunctive
medications for symptom relief of insomnia,
nausea, diarrhea, etc. usually are required.
Clonidine detoxification is best conducted on
an inpatient basis to ensure appropriate vital
sign monitoring. Inpatient treatment also
reduces the impulse to relapse, especially if
the detoxification is difficult.
Methadone detoxification can be continued
once a daily dose of 30 to 40mg is achieved, as
described above. The dose can be reduced to
20mg per day by a reduction of 5 to
10mg/week. Once the patient is on 20mg/day,
methadone can be reduced by 1 to 2mg daily,
depending on clinical measures of withdrawal. As with clonidine detoxification, the final
2 to 3 weeks of methadone detoxification is
associated with recidivism (relapsing).
Chapter 4
Inpatient treatment, if available, can provide

additional support, medical supervision, and
rehabilitative treatment that serve as disincentives to relapse.
Rapid and Ultrarapid

Detoxification
Although there are few data showing that the
rapid or ultrarapid methods of opioid detoxification show a positive correlation with the likelihood of a patients being abstinent a few
months later, efforts persist to make the detoxification process shorter and easier. This stems
in part from the desire of the person addicted
to opioids for a rapid, painless procedure, and
in part from an attempt to coax more such persons into treatment (fewer than one in five people with substance use disorders in the United
States are in treatment at any time) (Office of
National Drug Control Policy 2002). Another
contributing factor is the American cultures
search for rapidity in most endeavors. Finally,
the desire for rapid opioid detoxification is a
remnant of the belief system of a century ago,
when detoxification often was erroneously
equated with cure.
Rapid methods of detoxification have at their
core the use of narcotic antagonists; for example, naloxone, naltrexone, or nalmefene, to
precipitate narcotic withdrawal by displacing
exogenous opioids (those not produced by the
body itself) from the receptor sites. The ensuing severe symptoms then are managed by a
variety of medications and techniques. This
procedure was tried in the mid-1970s (Blachly
et al. 1975; Resnick et al. 1977), using naloxone
combined with benzodiazepines or propranolol
to ameliorate symptoms, but relief was insufficient for the technique to be considered useful.
With the discovery of clonidine as a nonopioid that could successfully treat much of the
withdrawal syndrome (Gold et al. 1978), the
method became more successful, but was still
problematic. Using combinations of clonidine,
naltrexone, benzodiazepines, and other
adjunct medications, the method was refined
and shortened during the 1980s (Charney et

al. 1982, 1986; Kleber et al. 1987; Riordan
and Kleber 1980; Vining et al. 1988) so that a
blocking dose of naltrexoneat least 25mg
usually was used by the second or third day
of treatment. The rate-limiting factor of this
rapid clonidine-naltrexone method is its
capacity to adequately relieve the precipitated withdrawal symptoms in the conscious
patient. Golden and Sakhrani (2004) found
that 25 percent of the 20 patients they studied
who were undergoing rapid detoxification
using clonidine and naltrexone developed
delirium and had to discontinue the procedure after the first day, and another patient
dropped out before completion.
The 1990s witnessed a variety of attempts to
overcome this barrier by using general anesthesia or heavy sedation. Although the ultrarapid procedure under anesthesia has
received wide publicity, controlled studies
that would make it possible to evaluate the
risk/benefit ratio are absent. The procedure
is still unproven and controversial. For a
brief review of studies done in this area, see
Stine and colleagues (2003).

Opioid detoxification, when properly conducted, usually can be concluded without significant patient discomfort. Aside from the compassionate goal of preventing unnecessary suffering, appropriate opioid detoxification
strengthens the therapeutic alliance between
the patient and clinician and prevents patients
from leaving treatment prematurely.
Discomfort also can indicate that too low a dose
of the detoxification agent is being administered. Mere symptomatic treatment is not a
substitute for reversing opioid withdrawal
and care should be taken to avoid masking
symptoms that would better respond to
detoxification.
Nevertheless, patients receiving adequate
detoxification doses still may complain of
symptoms that can be treated with adjunctive
73
medications. Insomnia can be treated with

diphenhydramine (Benadryl) 50 to 100mg,
trazodone (Desyrel) 75 to 200mg, or hydroxyzine (Vistaril) 25 to 50mg at bedtime.
Benzodiazepines should be avoided unless
required for concomitant alcohol or sedative
detoxification. Headache, muscle aches, and
bone pain can be managed with acetaminophen (e.g., Tylenol), aspirin, or ibuprofen
(e.g., Motrin) as needed. Abdominal cramps
are rare when the detoxification dose is sufficient but can be ameliorated with dicyclomine
(e.g., Bentyl) 10 to 20mg every 6 hours.
Mylanta or Maalox can be administered for
epigastric complaints and bismuth subcarbonate (e.g., Pepto-Bismol) 30 cc can be given
every 2 to 3 hours for diarrhea. Constipation,
a frequent complaint during methadone maintenance, usually can be managed with milk of
magnesia at 30 cc daily.
Opioid dependence, particularly intravenous
heroin dependence, is associated with a number of medical conditions. For this reason, a
complete physical examination, review of systems, and laboratory evaluation (when indicated) should be conducted. The patient
should be screened for tuberculosis as well as
for commonly encountered medical complications. These include HIV/AIDS, viral hepatitis (especially B and C), other sexually transmitted diseases, and opportunistic infections.
Injection sites should be examined for infection or abscess and patients should be
queried about night sweats, chills, nutritional
intake, diarrhea and gastrointestinal distress,
fever, and cough. History or evidence of trauma also should be elicited as part of a comprehensive assessment upon which a full
treatment plan will be based. In general,
patients should be ambulatory and able to
participate in rehabilitative activities during
detoxification. However, during the first 24
hours they may require bed rest or reduced
activity.
74
Benzodiazepines
and Other SedativeHypnotics
Intoxication and Withdrawal
Symptoms Associated With
Benzodiazepines and Other
Sedative-Hypnotics
Patients intoxicated with sedative-hypnotics
appear similar to individuals intoxicated with
alcohol. Slurred speech, ataxia, and poor physical coordination are prominent. If benzodiazepines are used alone, breath and blood alcohol levels should be zero. It should be remembered that benzodiazepines, when ingested
alone, intentionally, or accidentally in overdose, rarely lead to death by themselves.
Unfortunately, most individuals who ingest
benzodiazepines also may be using alcohol,
other sedative-hypnotics, or other drugs of
abuse, which in combination with benzodiazepines could be fatal if not managed appropriately.
Management of benzodiazepines and other
sedative-hypnotics in overdose is in part supported following principles of ACLS with particular attention to ventilation. Additionally,
removal of the benzodiazepine from the gastrointestinal tract using lavage and a cathartic is generally carried out, particularly if the
overdose is recent. Flumazenil (Romazicon) is
a competitive antagonist that acts at the benzodiazepine receptor. It can reverse the sedative and overdose effects of benzodiazepines
but not of alcohol or other sedative-hypnotics. The medication is administered via IV
by slow push (2 to 3 minutes) and dosage
varies, depending on whether one is treating
sedation reversal or overdose coma-reversal.
Flumazenil is only effective in benzodiazepine
overdose and is not an effective antidote
against other drugs. Clinicians should be
aware that in chronic benzodiazepine users
who are physically dependent, flumazenil
may induce seizures, high blood pressure,
Chapter 4
and delirium. So patients who are comatose

from benzodiazepines and are benzodiazepine
dependent may move quickly from coma to
acute benzodiazepine withdrawal symptoms
when flumazenil is administered.
Assessing the potential or actual severity of a
benzodiazepine and other sedative-hypnotic
abstinence syndrome is based primarily on
clinical information obtained from the patient,
significant others, and physical assessment.
Confirmation of length of benzodiazepine treatment with significant others, local pharmacies,
and treating physicians is useful. Specific name
of medication, dose, and duration of therapy
are vital. The presence or absence of alcohol
use is also important to know, as with the use of
other sedative-hypnotics, such as medications
for sleep. The existence of co-occurring psychiatric disorders such as panic disorder also are
important factors and should be investigated.
Cigarette smoking tends to induce the
metabolism of some benzodiazepines and this
can be a factor in scheduling a taper. Physical
assessment, with particular attention to mental
status, and neurologic exams are important.
Determination of vital signs also provides guidance. A urine drug screen may confirm the
presence of benzodiazepines but otherwise will
not be particularly helpful. Although sedativehypnotic withdrawal scales have been used in
research studies, they are not widely available
for clinical practice.
Medical complications of withdrawal from benzodiazepines include problems similar to those
seen in alcohol withdrawal. Seizures are particularly worrisome and may occur without being
preceded by other evidence of withdrawal. As
in alcohol withdrawal, seizures and delirium
represent the most extreme pathology seen.
Anecdotal reports appearing in the literature
also have described distortions in taste, smell,
and other perceptions. Since many individuals
who take benzodiazepines have underlying
anxiety disorders, it often is difficult during
periods of withdrawal to determine whether
symptomatology is related to withdrawal or the
emergence of panic attack symptoms. Elderly
patients who are being withdrawn from benzo-
diazepine are at risk for falls and myocardial

infarctions. Delirium without marked autonomic hyperactivity (no elevations of pulse,
blood pressure, or temperature) also may be
seen in the elderly. The management of benzodiazepine withdrawal is not recommended
without medical supervision. All benzodiazepines should be tapered rather than stopped
abruptly, regardless of dose or duration of
useunless it is a
matter of use for only
a few days (Ashton
2002).
Patients
Management
of
Withdrawal
With
Medications
intoxicated with
sedative-hypnotics
appear similar to
individuals
There are a limited

number of controlled
intoxicated with
trials that can provide guidance regardalcohol. Slurred
ing the management
of benzodiazepine
speech, ataxia,
and other sedativehypnotic withdrawal.
For reviews, see
and poor physical
Rickels and colleagues (1999) and
coordination are
Eickelberg and MayoSmith (1998). One
prominent.
strategy that is appropriate is to begin with
a slow taper of the
benzodiazepine that the patient already is taking. This taper may be conducted over several
weeks or perhaps even months. This may be
effective in cases of long-acting benzodiazepines
but often is not effective in detoxification from
short half-life benzodiazepines. Sometimes
switching to another benzodiazepine in a
patient who has had serious loss of control and
abuse problems with his primary agent is therapeutic. Another strategy is to switch the
patient to another benzodiazepine with a long
half-life. Frequently chlorodiazepoxide and
75
clonazepam are recommended. Figures 4-5 and

4-6 (p. 78) give the equivalent doses of these
medicines along with numerous other sedativehypnotics and benzodiazepines.
Another alternative is phenobarbital substitution. For patients who have used high doses of
benzodiazepines for an extended period of
time, hospitalization is always prudent.
Outpatient detoxification should be reserved
for patients whose doses of benzodiazepines
were mainly in therapeutic ranges, who do not
have polysubstance dependence, and who are
reliable and have reliable significant others to
aid in monitoring and supervising their
progress. In the outpatient setting, patients and
families need to be informed that even with
sound withdrawal treatment, seizures and
delirium are possible. The individual should be
instructed not to drive or operate dangerous
machinery during treatment and perhaps for
several weeks thereafter. Recurring assessment
will be necessary, particularly around times of
dosage reductions. Pregnant patients will need
to be detoxified slowly and in consultation with
an obstetrician.
A variety of cognitive and behavioral techniques have been proposed to assist in the presence of a medication taper. These techniques
alter negative cognitions regarding medication
cessation, provide patient education, and provide alternative cognitive and behavioral techniques for anxiety reduction and sleep
enhancement during detoxification (Spiegel
1999).
Anticonvulsants such as carbamazepine and
valproate, as well as sedating antidepressants
such as trazodone and imipramine, have been
advocated for use in withdrawal (Dickinson et
al. 2003). Rickels and colleagues (1999) assert
that these drugs have some beneficial effect in
the management of relatively low-dose benzodiazepine discontinuation in their ability to
reduce patients subjective complaints, but
76
that, in more severe withdrawal syndromes,

they do not decrease symptoms. Imipramine
can lower the seizure threshold and therefore
is not recommended. The use of anticonvulsants is probably best reserved as an adjunctive medicine to the long-acting benzodiazepine or phenobarbital. The use of buspirone for benzodiazepine detoxification is
ineffective and should not be considered. For
patients with major autonomic symptoms during withdrawal that cannot be controlled by
the primary treating agent, consideration of
the use of a low dose of clonidine or propranolol may be helpful.
Preparing patients and starting detoxification
during a period of low external stressors, with
patient commitment to tapering, and a plan to
manage underlying anxiety disorders, also are
important in detoxification. A flexible detoxification schedule is advised. During periods
of increased withdrawal symptoms, dosage
should be stabilized or even increased for a
period of days. Frequent in-person or phone
contact with the patient is vital. Patients
being detoxified in the outpatient setting may
need to be seen several times per week, especially at times of dosage reductions.
Stimulants
Cocaine and amphetamines (such as methamphetamine) are the most frequently abused central nervous system stimulants. These agents
are intensely rewarding and are self-administered by laboratory animals to the point of
death. Individuals dependent on stimulants
experience profound loss of control over stimulant intake, presumably in response to the
stimulation and disruption of endogenous (originating internally) reward centers (Dackis and
OBrien 2001). They often use stimulants in a
binge pattern that is followed by periods of
withdrawal. It is not clear whether craving
occurs predominantly during stimulant with-
Chapter 4
Figure 4-5
Benzodiazepines and Their Phenobarbital Withdrawal Equivalents
Generic name
Trade name
Therapeutic dose
range (mg/day)
Dose equal to
30mg of phenobarbital for withdrawal (mg)**
Phenobarbital
conversion
constant
Benzodiazepines
alprazolam
Xanax
0.756
30
chlordiazepoxide
Librium
15100
25
1.2
clonazepam
Klonopin
0.54
15
clorazepate
Tranxene
1560
7.5
diazepam
Valium
440
10
estazolam
ProSom
12
30
flumazenil
Mazicon
***
***
***
flurazepam
Dalmane
1530*
15
halazepam
Paxipam
60160
40
0.75
lorazepam
Ativan
116
15
midazolam
Versed
***
***
***
oxazepam
Serax
10120
10
prazepam
Centrax
2060
10
quazepam
Doral
15*
15
temazepam
Restoril
1530*
15
triazolam
Halcyon
0.1250.50*
0.25
120
* Usual hypnotic dose.

** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal
equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high-dose
withdrawal signs and symptoms.
*** Not applicable.
Source: American Psychiatric Association (APA) 1990; Wesson and Smith 1985.
77
Figure 4-6
Other Sedative-Hypnotics and Their Phenobarbital
Withdrawal Equivalents
Generic name
Trade
name(s)
Common
therapeutic
indication
Dose equal
to 30mg of
therapeutic
dose range
(mg/day)
Phenobarbital
for withdrawal (mg)**
amobarbital
Amytal
butabarbital
Conversion
constants
sedative
50150
100
0.33
Butisol
sedative
45120
100
0.33
butalbital
Fiorinal,
Sedapap
sedative/
analgesic*
100300
100
0.33
pentobarbital
Nembutal
hypnotic
50100
100
0.33
secobarbital
Seconal
hypnotic
50100
100
0.33
buspirone
Buspar
sedative
1560
***
***
chloral hydrate
Noctec,
Somnos
hypnotic
2501,000
500
0.06
ethchlorvynol
Placidyl
hypnotic
5001,000
500
0.06
glutethimide
Doriden
hypnotic
250500
250
0.12
meprobamate
Miltown,
Equanil,
Equagesic
sedative
1,2001,600
1,200
0.025
methylprylon
Noludar
hypnotic
200400
200
0.15
Barbiturates
Others
* Butalbital usually is available in combination with opioid or non-opioid analgesics.

** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal
equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high-dose
withdrawal signs and symptoms.
*** Not cross-tolerant with barbiturates.
Source: APA 1990; Wesson and Smith 1985.
78
Chapter 4
drawal or after these symptoms have largely

disappeared. While the processes that govern
addiction to cocaine and amphetamines are
believed to be similar, recent animal research
suggests that there are also subtle differences in
the ways in which these two types of drugs create sensitization (and perhaps addiction) in regular users (Li et al. 2005).
Stimulant Withdrawal
Symptoms
Stimulants are associated with withdrawal
symptoms that differ markedly from those seen
with opioid, alcohol, and sedative dependence
(see Figure 4-7). While most clinicians believe
that alcohol and heroin withdrawal should be
treated aggressively with detoxification, there
has been little emphasis on treating symptoms
of stimulant withdrawal. Consequently, no
medications have been developed for this purpose. This situation is understandable because
stimulant withdrawal usually does not involve
medical danger or intense patient discomfort.
However, if stimulant withdrawal predicts poor
outcome, it may be a reasonable target for clinical interventions.
An often overlooked but potentially lethal
medical danger during stimulant withdrawal
is the risk of a profound dysphoria (depression, negative thoughts and feelings) that may
include suicidal ideas or attempts. This may
be, in part, a physiological response to cocaine
or amphetamine withdrawal and, in part, a

reaction to individuals acute realization of the
devastating psychosocial consequences after a
binge ends. While both cocaine and
amphetamine users may experience depression
during withdrawal, the period of depression
experienced by amphetamine users is more
prolonged and may be more intense.
Amphetamine users, in particular, should be
monitored closely during detoxification for
signs of suicidality and treated for depression if
appropriate.
Although the literature on cocaine withdrawal
is controversial, reasonable consensus supports
the constellation of symptoms depicted in
Figure 4-7 (Coffey et al. 2000; Cottler et al.
1993). These symptoms often disappear after
several days of stimulant abstinence but can
persist for 3 to 4 weeks (Coffey et al. 2000). In
addition, since individuals addicted to stimulants often fail to achieve abstinence, withdrawal symptoms can be a persistent component of
active addiction. In addition, individuals
addicted to stimulants may experience impairment in hedonic function (ability to experience
pleasure) that has been ascribed to stimulantinduced disruptions of endogenous reward centers (Dackis and OBrien 2002). Research on
animals has found that exposure to high doses
of methamphetamine results in changes to both
the dopaminergic and serotonergic systems of
the brain (Nordahl et al. 2005) and dopamine
abnormalities among animals and humans who
had been ingesting cocaine (Schuckit 2000).
Figure 4-7
Stimulant Withdrawal Symptoms
Depresion
Poor concentration
Hypersomnia (or insomnia)
Psychomotor retardation
Fatigue
Increased appetite
Anxiety
Paranoia
Irritability
Drug craving
79
Researchers have also observed abnormalities

in regions of the brain that govern attention
and memory in animals that were regularly
administered methamphetamine (Nordahl et al.
2005).
Although cocaine withdrawal has traditionally
been viewed as relatively mild (Satel et al.
1991; Weddington et al. 1990), evidence suggests that individuals dependent on cocaine
with severe stimulant withdrawal are more likely to have a poor clinical outcome (Kampman
et al. 2001a). The level of withdrawal symptoms, therefore, may be clinically significant
and should be monitored and recorded for
future treatment (Kampman et al. 2001b).
Kampman reported significantly higher
dropout rates in individuals dependent on
cocaine who scored high on the Cocaine
Selective Severity Assessment (CSSA), a reliable and valid structured interview designed to
capture cocaine withdrawal symptoms
(Kampman et al. 1998). Patients with high
scores on the CSSA were five times more likely
to leave treatment and four times more likely to
resume cocaine use than those with low scores
(Mulvaney et al. 1999). The CSSA is an easily
administered 18-item questionnaire. Each item
is a 7-point rating scale, so that a person can
score a number of points on any given question. Scores in excess of 22 indicate the presence of significant cocaine withdrawal. See
appendix C for more information on the CSSA.
Given the poor prognosis associated with
cocaine withdrawal, it is reasonable that more
clinical attention be directed toward this phenomenon.
Stimulant Withdrawal
As previously noted, stimulant withdrawal is
not usually associated with medical complications. However, patients with recent cocaine
use can experience persistent cardiac complications, including prolonged QTc interval and
vulnerability for arrhythmia and myocardial
infarction (Chakko and Myerburg 1995). QT is
an interval of time that can be measured on an
80
electrocardiogram (between the q wave and the

t wave), while QTc is the relative (or corrected) QT interval. Some conditions and many
drugs (LAAM, other opioids, and even antibiotics) can cause the interval to lengthen and
this can result in cardiac rhythm disturbances.
Anterior chest pain or cardiac symptoms
should therefore be fully evaluated in these
individuals. Seizures also may be a complication of stimulant abuse and can occur during
detoxification. Persistent headaches could represent a subdural, subarachnoid, or intracerebral bleed (bleeding in or around the brain)
and should be appropriately evaluated. It also
should be emphasized that people who abuse
stimulants usually become addicted to other
substances, such as alcohol, sedatives, or opioids, and therefore can experience any of the
complications ascribed to detoxification from
these substances. Covert (secretive) use of
other substances should be suspected and
assessed with urine toxicology.
Without Medications
The most effective means of treating stimulant
withdrawal involves establishing a period of
abstinence from these agents. Access to brief
hospitalization, a level of care previously available for those who abuse stimulants, has been
largely eliminated by managed care initiatives.
In its place, intensive outpatient treatment can
assist the patient to cease use long enough for
withdrawal symptoms to abate entirely.
Rehabilitative approaches to achieve stimulant
abstinence have been reviewed elsewhere
(Dackis and OBrien 2001). The avoidance of
cue-induced craving is particularly important
in these individuals, especially in light of
research that shows limbic activation (activity
in a certain part of the brain) in response to
cue-induced craving (Childress et al. 1999). It
also is important that individuals dependent on
stimulants abstain from other addictive substances.
Chapter 4
With Medications
There are no medications with proven efficacy
to treat stimulant withdrawal. However,
researchers have investigated some medications
for cocaine detoxification. Amantadine may
help reduce cocaine use in patients with more
severe withdrawal symptoms (Kampman et al.
2000). Modafinil, an antinarcolepsy agent with
stimulant-like action, is currently under investigation by one research group as a cocaine
detoxification agent (Dackis and OBrien
2002). One small study in Thailand found the
antidepressant mirtazapine (Remeron) was
effective at reducing a number of the symptoms
associated with amphetamine withdrawal
(Kongsakon et al. 2005). None of these medications, however, are approved for use in treating
stimulant withdrawal and further research is
needed. Gorelick and colleagues (2004) review
the full range of clinical literature on pharmacological intervention for cocaine addiction.

Since stimulant withdrawal is not associated
with severe physical symptoms, adjunctive
medications are seldom required. These
patients often are sleep deprived and might be
unable to benefit from therapeutic activities
during the first 24 to 36 hours of abstinence.
They often are hungry and in need of large
meal portions initially as their food intake may
have been inadequate during active addiction.
Stimulant users also may be irritable and care
should be taken to avoid needless confrontation
during the initial withdrawal phase. Headaches
often are reported and can be treated symptomatically. Persistent headaches should be
evaluated, as cocaine can produce cerebrovascular disease. Similarly, chest pain of possible
cardiac origin should be evaluated medically
with electrocardiography, cardiac enzymes,
and appropriate medical attention. On occasion, patients undergoing withdrawal from
cocaine or amphetamines report insomnia and
may benefit from diphenhydramine (Benadryl)
50 to 100mg, trazodone (Desyrel) 75 to 200mg,
or hydroxyzine (Vistaril) 25 to 50mg at bedtime. Benzodiazepines should be avoided unless

required for concomitant alcohol or sedative
detoxification. As stimulant withdrawal symptoms wane, patients are best treated with an
active rehabilitative approach that combines
entry into substance abuse treatment with support, education, and changes in lifestyle.
Other Immediate Concerns

Central nervous system stimulants exert most
of their toxic effects through vasoconstriction
(constriction of the blood vessels).
Consequently, a number of medical conditions
can arise from
ischemia (lack of
proper blood supply)
Intensive
or infarction (death
of tissue as the result
outpatient
of lack of blood supply) as a result of
treatment can
stimulant use.
Myocardial (heart
assist the patient
muscle) infarction
and stroke are widely
recognized complicato cease use long
tions of stimulant use.
However, other probenough for
lems such as spontaneous abortion, bowel
withdrawal
necrosis (tissue
death), and renal
symptoms to abate
(kidney) infarction
also have been
entirely.
reported from
cocaine-induced vasoconstriction. Cardiac
arrhythmias also are common. Other medical
problems that are associated with stimulant
dependence include dental disease, neuropsychiatric abnormalities, and movement disturbances/disorders.
Antidepressants, such as selective serotonin
reuptake inhibitors, can be prescribed for the
depression that often accompanies methamphetamine or other amphetamine withdrawal.
81
Inhalants/Solvents
Withdrawal Symptoms
Associated With
Inhalants/Solvents
The term inhalants is used to describe a
large and varied group of psychoactive substances that all share the common characteristic of being inhaled for their effects. They are
commonly found in household, industrial, and
medical products. These drugs are used primarily by adolescents, although some, especially the nitrates, are used by adults as well
(NIDA 2000). Figure 4-8 presents some of the
more commonly abused inhalants.
Dependence on inhalants and subsequent
withdrawal symptoms are both relatively
uncommon phenomena (Balster 2003). There
is no specific or characteristic withdrawal
syndrome that would include all drugs in the
inhalant class. Intoxication with the solvents,
aerosols, and gases often produces a syndrome most like that of alcohol intoxication
but lasting only 15 to 45 minutes (Miller and
Gold 1990). Rarely, symptoms similar to
sedative withdrawal have been described,
including fine tremors, irritability, anxiety,
insomnia, tingling sensations, seizures and
muscle cramps (Miller and Gold 1990, p.
87). Toluene withdrawal has been reported to
cause delirium tremens (Miller and Gold
1990). Longtime users also may exhibit weakness, weight loss, inattentive behavior, and
depression (NIDA 2005). It has been reported
that withdrawal symptoms can occur with as
little as 3 months of regular usage (Ron 1986).
When present, the withdrawal typically lasts
2 to 5 days (Evans and Raistrick 1987).
In addition to their short-term intoxicating
affects, nitrates are used to enhance sexual
pleasure by vasodilation (dilation of blood
vessels) that produces a rush and sensation of
warmth. There is no withdrawal syndrome
that has been associated with nitrate abuse.
82
There are no specific assessment instruments

available to measure inhalant withdrawal
symptoms. A patient who presents with a history of inhalant use and symptoms of sedative-like withdrawal should alert the clinician
to the possibility of inhalant withdrawal.
These patients require a complete history and
physical exam. Additionally, a blood alcohol
level and urine drug screen are helpful in the
cases of suspected polydrug abuse.
Withdrawal From
Inhalants/Solvents
There are a large number of medical complications associated with inhalant abuse and intoxication. Many of these complications are not the
result of withdrawal but may still be seen when
the patient presents to the clinician. Most
inhalants produce some neurotoxicity with cognitive, motor, and sensory involvement.
Additionally, damage to internal organs including the heart, lungs, kidneys, liver, pancreas,
and bone marrow has been reported.
Without Medications
It is crucial to provide the patient with an environment of safety that removes him from access
to inhalants. This can pose a challenge due to
the almost universal availability of these drugs
in society. Many of the medical consequences of
inhalant usage will remit once the patient
achieves abstinence (Balster 2003). The patient
should be monitored for withdrawal symptoms
and changes in mental status.
Most patients presenting for treatment of
inhalant dependence will be adolescents.
Ideally, they should be entered into an ageappropriate treatment program that meets
their medical and psychosocial needs.
Supportive care, including helping them to get
enough sleep and a well-balanced diet, usually
will be sufficient to get patients safely through
withdrawal (Frances and Miller 1998).
Chapter 4
Figure 4-8
Commonly Abused Inhalants/Solvents
Type
Example
Chemicals in Inhalant/Solvent
Adhesives
Airplane glue
Toluene, ethyl acetate
Other glues
Hexane, toluene, methyl chloride, acetone, methyl ethyl

ketone, methyl butyl ketone
Special cements
Trichloroethylene, tetrachloroethylene
Spray paint
Butane, propane (U.S.), fluorocarbons, toluene, hydrocarbons, Texas shoe shine (a spray containing toluene)
Hair spray
Butane, propane (U.S.), chlorofluorocarbons (CFCs)
Deodorant; air freshener
Butane, propane (U.S.), CFCs
Analgesic spray
CFCs
Asthma spray
CFCs
Fabric spray
Butane, trichloroethane
PC cleaner
Dimethyl ether, hydrofluorocarbons
Gaseous
Nitrous oxide
Liquid
Halothane, enflurane
Local
Ethyl chloride
Dry cleaning
Tetrachloroethylene, trichloroethane
Spot remover
Xylene, petroleum distillates, chlorohydrocarbons
Degreaser
Tetrachloroethylene, trichloroethane, trichloroethylene
Aerosols
Anesthetics
Cleaning agents
With Medications
Patients presenting with only inhalant withdrawal are unusual. Clinicians should promptly ascertain if the patient has been abusing any
other substances and proceed with appropriate
detoxification as clinically indicated. When a
patient presents with (1) a history of extensive
inhalant usage, (2) a sedative-like withdrawal
syndrome, and (3) no significant history or laboratory data that supports other substances,
then the clinician can assume that the patient is
in inhalant withdrawal.
As noted before, withdrawal from inhalants is
similar to withdrawal from sedative-hypnotics. No systematic detoxification protocol
has been established, although some clinicians

have found phenobarbital useful (CSAT
1995d). The usefulness of benzodiazepines is
unknown but would seem a reasonable alternative given our current understanding of
inhalant withdrawal (Brouette and Anton
2001). No other medications have been routinely used for inhalant withdrawal.

For patients who have only been abusing
inhalants, treatment of insomnia during withdrawal is not usually necessary. Sedative substitution during the period of detoxification
may allow the patient to sleep. However, a
period of postdetoxification insomnia should
be expected and usually can be treated by the
83
Figure 4-8 (continued)

Commonly Abused Inhalants/Solvents
Solvents and gases Nail polish remover
Acetone, ethyl acetate
Paint remover
Toluene, methylene chloride, methanol acetone, ethyl

acetate
Paint thinner
Petroleum distillates, esters, acetone
Correction fluid and thinner Trichloroethylene, trichloroethane
Food products
Fuel gas
Butane, isopropane
Lighter
Butane, isopropane
Fire extinguisher
Bromochlorodifluoromethane
Whipped cream
Nitrous oxide
Whippets
Nitrous oxide
Room odorizers Locker Room, Rush,

Poppers
Isoamyl, isobutyl, isopropyl or butyl nitrate (now legal),

cyclohexyl
Source: Balster 2003.

recommendation of good sleep hygiene practices such as avoiding caffeine, daytime napping, and overstimulation in the evening.
If the patient is able to refrain from inhalant
(and other substance) use and has no serious
psychiatric or medical consequences, then
outpatient treatment should be the first
option. Inpatient or residential treatment
should be used for those patients who cannot
achieve abstinence or have serious co-occurring medical or psychiatric disorders.
Hospitalized patients will need a thorough
history and physical exam. Therapy to
address denial, addiction, and pertinent psychosocial issues should be initiated as soon as
possible during the hospitalization.
Supportive care and abstinence will resolve
most medical problems associated with chronic inhalant usage (Balster 2003).
84
Nicotine
In 2004, approximately 44.5 million adults
were cigarette smokers (23.4 percent were
men and 18.5 percent were women) (CDC
2005a). Nicotine addiction in the form of
cigarette smoking accounts for more deaths
each year than AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes,
and fires combined (U.S. Department of
Health and Human Services [U.S. DHHS]
2000b). Between 1995 and 1999, there were
490,000 smoking-related premature deaths
annually, and smoking cost the country at
least $157 billion yearly in health-related economic losses. This amounts to approximately
$7.18 per pack of cigarettes (Fellows et al.
2002), a truly staggering figure.
Smokers are at increased risk for several
medical problems, including myocardial
infarction, coronary artery disease, hypertension, stroke, peripheral vascular disease,
Chapter 4
chronic obstructive lung disease, chronic

bronchitis, and several types of cancer (lung,
stomach, head and neck, and bladder). Other
problems associated with nicotine addiction
include gastro-esophageal reflux disease and
gastric ulcerations, cataracts, and premature
wrinkling of the skin. There also appears to
be an antiestrogen effect (suppression of an
important hormone) that may lead to early
development of osteoporosis in women
(Okuyemi et al. 2000).
In 1988, the U.S. Surgeon Generals Report
concluded that nicotine is the principal addictive agent in tobacco. Nicotine binds to nicotinic acetylcholine receptors in the brain and
has the direct ability to stimulate the release
of dopamine in the nucleus accumbens area.
The nucleus accumbens has long been considered the reward center in the brain. This
increase in dopamine is similar to what occurs
when patients use stimulants and is felt to be
an essential element in the reward process of
addiction (Glover and Glover 2001).
As many as 90 percent of patients entering
treatment for substance abuse are current
nicotine users (Perine and Schare 1999).
There has long been controversy in the field
of addiction medicine as to how best to handle
the problem of nicotine dependence in
patients seeking treatment for other types of
substance abuse. Traditionally, it has been
argued that patients would find that trying to
stop smoking while also contending with other
(more pressing) addiction problems would be
too difficult and distracting in early abstinence. However, others argue that nicotine
dependence is a lethal disease and that physicians have the responsibility to intervene in
this addiction with the same aggressiveness
they show toward other addictive substances.
This pro-intervention position has received
increasing attention from clinicians, inasmuch
as it is now understood that alcohol consumption is associated with increased nicotine
usage (Henningfield et al. 1984). Gulliver and
colleagues (1995) have demonstrated that the
urge to smoke is correlated with the urge to
drink, and others have shown that continued

nicotine dependence may be a relapse trigger
for resumption of drinking (Stuyt 1997). The
concern that smoking cessation may precipitate relapse to other substances of abuse has
not been supported in the literature (Hughes
1995).
Treatment programs that have attempted to
treat nicotine dependence in conjunction with
other drugs of addiction have met with limited success (Bobo and Davis 1993; Burling et
al. 1991; Hurt et al. 1994) and have generated increased interest in smoking cessation as
a part of a patients overall substance abuse
treatment (Sees and Clark 1993). One study
reported that forcing unmotivated patients
(or patients who did not consider smoking a
problem) to quit was countertherapeutic
(Trudeau et al. 1995).
Moreover, it has traditionally been accepted
that nicotine detoxification concurrent with
detoxification from other substances makes
the undertaking more difficult. Several factors are involved including the following: (1)
patient ambivalence and/or lack of interest in
smoking cessation; (2) physician ambivalence
about the importance of smoking cessation
early in treatment; (3) staffs use of nicotine;
(4) staffs ambivalence about the importance
of nicotine cessation early in treatment; (5)
easy availability of cigarettes from peers,
family, visitors, staff, and at 12-Step meetings; (6) lack of sufficient training and expertise on the part of physicians and staff in
managing nicotine withdrawal; and (7) staff
resistance to patient smoking cessation
because withdrawal symptoms include irritability, anxiety, and depression, all of which
can make patients more difficult to manage.
Withdrawal Symptoms
Associated With Nicotine
The Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, text revision
(DSM-IV-TR) (APA 2000) notes that typically,
a person in nicotine withdrawal will have four
85
or more of the signs presented in Figure 4-9,

though some clinicians believe that three or
more is sufficient to make the diagnosis of
nicotine withdrawal. Furthermore, it should
be noted that symptoms vary in duration and
intensity, with decreased heart rate and lightheadedness resolving in 48 hours, while
increased appetite may remain present for
weeks to months (Glover and Glover 2001).
Smokers who have severe craving during
withdrawal are less likely to be successful in
their attempt at quitting (Hughes and
Hatsukami 1992). Depression during withdrawal also has been linked to relapse to
smoking (Covey et al. 1993).
Assessing Severity
Since 1978, the standard instrument used to
measure physical dependence on nicotine has
been the eight-item Fagerstrom Tolerance
Questionnaire (FTQ) (Fagerstrom 1978). A
later revision known as the Fagerstrom Test
for Nicotine Dependence (FTND) (see Figure
4-10) has been reduced to six questions

(Giovino et al. 1995; Heatherton et al. 1991).
Scores greater than seven are consistent with
nicotine dependence.
While both the FTQ and FTND are very useful for estimating a patients physical dependence on nicotine, there is still a need to
assess more accurately the degree to which
smoking behavior plays a role in maintaining
addiction. The Glover-Nilsson Smoking
Behavioral Questionnaire (GN-SBQ) is an 11question, self-administered test that evaluates
the impact of behaviors and rituals associated
with smoking (see Figure 4-11, p. 88). It was
designed to assist clinicians in identifying and
quantifying behavioral aspects of smoking
that play a role in maintaining nicotine
dependence, which can then help the clinician
develop a cessation strategy that takes into
account both physical dependence and behavioral dependence (Glover et al. 2002).
Figure 4-9
DSM-IV-TR on Nicotine Withdrawal
A. Daily use of nicotine for at least several weeks.
B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24
hours by 4 or more of the following signs:
1. Dysphoric or depressed mood
2. Insomnia
3. Irritability, frustration, or anger
4. Anxiety
5. Difficulty concentrating
6. Restlessness
7. Decreased heart rate
8. Increased appetite or weight gain
C. The symptoms of Criterion B cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder.
Source: APA 2000, pp. 244245.

86
Chapter 4
Figure 4-10
Items and Scoring for the Fagerstrom Test for Nicotine Dependence
Questions
Answers
Points
1. How soon after you wake up do you smoke your

first cigarette?
Within 5 minutes
630 minutes
3160 minutes
After 60 minutes
3
2
1
0
2. Do you find it difficult to refrain from smoking in

places where it is forbidden (e.g., in church, at the
library, in the cinema, etc.)?
Yes
No
1
0
3. Which cigarette would you hate most to give up?
The first thing in the morning

All others
1
0
4. How many cigarettes/day do you smoke?
10 or less
1120
2130
31 or more
0
1
2
3
5. Do you smoke more frequently during the first

hours of waking than during the rest of the day?
Yes
No
1
2
6. Do you smoke if you are so ill that you are in bed

most of the day?
Yes
No
1
0
Source: APA 1996.

To better understand a patients level of nicotine dependence, providers can assess biochemical markers including nicotine, cotinine, and carbon monoxide. Nicotine and its
metabolite cotinine can be measured in urine,
blood, or saliva. Cotinine continues to be present in bodily fluids for up to 7 days after cessation. Clinicians should use caution when
interpreting the meaning of nicotine and cotinine assays, as they are not specific to tobacco-derived nicotine and may indicate the
patients compliance with nicotine replacement therapy rather than smoking.
Carbon monoxide is easily measured in
expired breath and can show whether the
patient has been smoking within a few hours
prior to the test. It can be used to monitor
smoking cessation for patients receiving nico-
tine replacement therapy and patients often

find it a helpful motivator in their attempt to
maintain abstinence (Benowitz 1983).
Withdrawal From Nicotine
There are no major medical complications precipitated by nicotine withdrawal itself.
However, patients frequently experience
uncomfortable withdrawal symptoms starting
within a few hours of cessation. In addition to
the symptoms previously noted, patients may
complain of increased coughing, a desire for
sweets, and difficulty concentrating (Hughes
and Hatsukami 1992). Clinicians should be
aware that withdrawal symptoms can masquer-
87
Figure 4-11
The Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ)
Please indicate your choice by circling the number that best reflects your choice.
0 = Not at all; 1 = Somewhat; 2 = Moderately so; 3 = Very much so; 4 = Extremely so
How much do you value the following (Specific to Questions 12)?
1. My cigarette habit is very important to me.
2. I handle and manipulate my cigarette as part of the ritual of smoking.
3. Do you place something in your mouth to distract you from smoking?
4. Do you reward yourself with a cigarette after accomplishing a task?
5. If you find yourself without cigarettes, will you have difficulties in concentrating
before attempting a task?
6. If you are not allowed to smoke in certain places, do you then play with your
cigarette pack or a cigarette?
7. Do certain environmental cues trigger your smoking (e.g., favorite chair, sofa,
room, car, or drinking alcohol)?
8. Do you find yourself lighting up a cigarette routinely (without craving)?
9. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick,
chewing gum, etc.) in your mouth and sucking to get relief from stress, tension or
frustration, etc.?
10. Does part of your enjoyment of smoking come from the steps (ritual) you take
when lighting up?
11. When you are alone in a restaurant, bus terminal, party, etc., do you feel safe,
secure, or more confident if you are holding a cigarette?
Please indicate your choice by circling the number that best reflects your choice.
(Specific to Questions 311).
0 = never; 1 = seldom; 2 = sometimes; 3 = often; 4 = Always
TOTAL_______
Scoring for Behavioral Dependence
<12 Mild
1222 Moderate
2333 Strong
>33 Very Strong
Source: Glover et al. 2002

88
Chapter 4
ade as other psychiatric conditions, especially

anxiety and depression (see Figure 4-12).
Smoking cessation also may affect the
metabolism of other drugs primarily through
the Cytochrome P 450 (CYP450) system. This
system is one of many hepatic liver enzyme systems that is responsible for the metabolic
breakdown of various drugs into inactive compound products. Different drugs and compounds have varying affinities for the CYP450
system. The higher the affinity, the faster the
breakdown of the drug or compound in the
body. Some compounds can slow the
metabolism or breakdown of other drugs with a
lower affinity, leading to a buildup of that drug
or compound in the body.
During detoxification from nicotine, some
medications will have their metabolism
altered, including theophylline, caffeine,
tacrine, imipramine, haloperidol, pentazocine, propranolol, flecainide, and estradiol;
in general, these effects are short-lived and
seldom drastic. Nicotine also reduces beta
blockers ability to lower blood pressure and
heart rate and decreases the amount of sedation from benzodiazepines as well as decreases the amount of pain relief provided by
some opioids, most likely because of its stimulant effects (Zevin and Benowitz 1999). A
complete discussion of nicotines effects on
medications is beyond the scope of this TIP
and physicians are encouraged to consult the
Physicians Desk Reference (2004) or equiva-
lent pharmaceutical guide. Figure

4-13 (p. 90) shows the effects of abstinence
from smoking on blood levels of a number of
medications.
Without Medications
About one third of current smokers attempt
to quit smoking each year and more than 90
percent of these try to do so without any formal nicotine cessation treatment. Most smokers will make several attempts on their own to
quit and ultimately, only about 50 percent are
successful over a lifetime (U.S. DHHS 2000b).
While some smokers are able to quit on their
own, others may require intervention in the
form of behavioral treatment and/or pharmacotherapy.
There are insufficient data available to determine who will benefit most from a particular
type of treatment. Some patients may prefer
to stop smoking without the use of medication. An elevated score on the GN-SBQ would
indicate a strong behavioral component to
smoking that might guide the clinician in recommending behavioral treatment as a primary intervention. Patients who also have elevated FTQ scores may benefit by a combination of behavioral and pharmaceutical intervention.
Figure 4-12
Some Examples of Nicotine Withdrawal Symptoms That Can Be
Confused With Other Psychiatric Conditions
Anxiety
Depression
Increased REM (rapid eye movement) sleep
Insomnia
Irritability
Restlessness
Weight gain
Source: APA 1996.

89
Figure 4-13
Effects of Abstinence From Smoking on Blood Levels of
Psychiatric Medications
Abstinence Increases Blood
Levels
Abstinence Does Not Increase

Blood Levels
Effect of Abstinence on Blood

Levels Is Unclear
Clomipramine
Clozapine
Desipramine
Desmethyldiazepam
Doxepin
Fluphenazine
Haloperidol
Imipramine
Oxazepam
Nortriptyline
Propranolol
Amitriptyline
Chlordiazepoxide
Ethanol
Lorazepam
Midazolam
Triazolam
Alprazolam
Chlorpromazine
Diazepam
Source: APA 1996.

The U.S. Public Health Services Treating
Tobacco Use and Dependence: Clinical
Practice Guideline is a comprehensive review
of the smoking cessation literature (Fiore et
al. 2000a). It discusses a range of nonpharmacological interventions for the management
of withdrawal from nicotine; these can be separated into two basic categories: self-help
interventions and behavioral interventions
(Anderson and Wetter 1997).
Self-help interventions
Many tobacco users prefer to attempt to quit
without any assistance from professionals. A
number of self-help products are available
that can assist them in their cessation
attempts. These include a wide array of pamphlets, manuals, video- and audiotapes (e.g.,
from the American Lung Association and the
National Cancer Institute), 12-Step self-help
support groups, and telephone helplines. The
U.S. Public Health Services Guideline, which
analyzed all types of self-help interventions
together, found that the self-help approach to
cessation yielded results only slightly better
than no intervention at all. To date, self-help
90
interventions alone have not been very successful at helping people achieve abstinence
from tobacco. The Guideline suggests, however, that self-help can be a useful adjunct to
other forms of treatment (Fiore et al. 2000a).
One type of self-help intervention that shows
some promise is the use of computer-generated personalized written feedback for patients.
The computer makes recommendations based
on an individuals response to standardized
questions about her smoking (Etter and
Perneger 2001; Shiffman et al. 2000).
Behavioral interventions
The U.S. Public Health Service study noted
that when physicians took as little as 3 minutes to advise their patients to stop smoking,
long-term quit rates were modestly improved
from 7.9 percent to 10.2 percent (Fiore et al.
2000a). Westmaas and colleagues note that
simple, clear advice from a physician can be
considered an easy, cost-effective intervention
that not only moves smokers closer to the
decision to quit, but also may motivate some
smokers to make an actual attempt
Chapter 4
(Westmaas et al. 2000, p. 58). The greater the

amount of time in face-to-face interventions,
the higher the success rate for patients, but
interventions as short as 3 minutes have been
found to be effective (Fiore et al. 2000a). A
counseling session of longer than 10 minutes
produced a cessation rate of 20.1 percent
compared to a rate of 10.9 percent for no
treatment. The guideline also indicated that if
cessation information is given by multiple
types of providers (e.g., physician, psychologist, dentist, nurse, and pharmacist) it can
have a dramatic effect on cessation rates,
increasing the rate to 23 percent compared to
10.8 percent for patients who had no
provider contact.
A review of behavioral intervention studies
concluded that both supportive care by a
clinician and the ability of patients to develop
problemsolving and coping skills improved
success rates for smoking cessation (Anderson
and Wetter 1997). Other components such as
cigarette fading (gradually decreasing the
number of cigarettes smoked over a period of
time), establishing a quit date, enhanced environmental support, improved diet and
increased exercise, relaxation training, and
contingency contracting were not associated
with improved outcome. Aversive conditioning, such as rapid smoking techniques, is
effective but not routinely recommended

(Fiore et al. 2000a).
With Medications
A U.S. Public Health Service panel recommends that all primary care physicians provide a five-step intervention, known as the 5
As, to all tobacco users. The panel recommends that all smokers who want to quit
should be offered active medication that has
been approved for assisting in smoking cessation unless there is a medical contraindication
(Fiore et al. 2000a). Figure 4-14 provides a
summary of the 5 As for brief intervention.
Nicotine Replacement
Therapy (NRT)
Nicotine polacrilex gum was approved by the
FDA in 1984. In the 1990s other NRTs received
FDA approval, including the nicotine transdermal patch, the nicotine nasal spray, and the
nicotine inhaler. Nicotine gum and nicotine
transdermal patch are now available over the
counter. After the acute withdrawal period,
patients are then weaned off the medication
until they become nicotine free. All NRTs are
Figure 4-14
The 5 As for Brief Intervention
Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.
Advise to quit. In a clear, strong, and personalized manner urge every tobacco user to quit.
Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this
time?
Assist in quit attempt. For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit.
Arrange followup. Schedule followup contact, preferably within the first week after the quit date.
Source: Fiore et al. 2000a, p. 26.
91
effective, with 1-year quit rates between 11 and

34 percent (Okuyemi et al. 2000).
There has been some concern about the
addictive potential of NRTs, and it has been
reported that 5 to 20 percent of patients using
nicotine polacrilex gum continue to use it for
more than 1 year (Hughes 1989). There was
also initial concern that the nicotine nasal
spray, with its rapid onset of action and high
plasma concentrations, might become a drug
of abuse. This has not been reported in the
literature, and it
could be speculated
that this is because
of the nasal sprays
relatively uncomPatients should be
fortable side effects
that cause many
encouraged to use
patients to dislike
the product (Schuh
combined NRT
et al. 1997). In general, withdrawal
symptoms from
treatments if they
NRTs are mild compared to those that
are unable to quit
occur in smoking
cessation, and conusing a single type
tinued use of these
products may be the
of first line
result of patients
fear of returning to
pharmacotherapy.
active smoking
(APA 1996). For
those patients who
continue to use
NRTs, providers
should balance the patients continued dependence on nicotine with the considerable
health benefit of decreasing active tobacco
usage. It is clear that constituents of tobacco
other than nicotine are responsible for causing cancer. No ill effects have been attributed
to long-term use of nicotine replacement therapy (Benowitz and Gourlay 1997).
Bupropion SR
Bupropion SR (Sustained Release) was initially
manufactured under the name Wellbutrin as a
treatment for major depressive disorder. In
1997, the FDA approved bupropion SR for
smoking cessation, and it has been marketed
under the name Zyban. Bupropion is a novel
antidepressant that is involved primarily with
dopamine but also affects adrenergic mechanisms in the central nervous system. Its exact
mechanism of action is unknown, but it is not a
nicotine substitute or replacement like the
NRTs. The recommended dose is 150mg daily
for 3 days and then 150mg twice daily for 7 to
12 weeks. Typically patients set their quit date
1 to 2 weeks from the time they start the medication in order to get the drug to therapeutic
levels. This is an ideal time for the patient to
focus on making behavioral changes and enlisting social support to augment his quit attempt.
Bupropion SR has proven useful in smoking
cessation with a 12-month abstinence rate of
35.5 percent compared to a placebo at 15.6
percent and the nicotine patch at 16.4 percent
(Westmaas et al. 2000). The most commonly
reported side effects include dry mouth and
insomnia. Bupropion SR should not be used in
patients with a history of seizures, heavy alcohol use, head trauma, or with anorexia or
bulimia.
Other nonnicotine
pharmacotherapy
Covey and colleagues examined nonnicotine
pharmaceutical products that have been evaluated in controlled trials of smoking cessation
(Covey et al. 2000). These drugs include the
following:
The alpha-2 agonist antihypertensive,
clonidine
The tricyclic antidepressant, nortriptyline
The monoamine oxidase inhibitor (MAOI)
antidepressant, moclobemide
The serotonin 5-HT1A agonist anxiolytic,
buspirone
92
Chapter 4
The antihypertensive CNS nicotinic receptor

blocker, mecamylamine
Oral dextrose tablets
Although none of these agents has been
approved by the FDA for smoking cessation,
clonidine, nortriptyline, and moclobemide have
all been found to be effective treatments (Covey
et al. 2000). Clonidine may be a helpful
adjunct to nicotine replacement during acute
nicotine withdrawal. Doses of 0.05mg to 0.1mg
three times a day can be tried as tolerated
(sedation and low blood pressure are concerns), and the medication needs to be tapered
when discontinued to avoid rebound hypertension.
The Public Health Services Treating
Tobacco Use and Dependence: Clinical
Practice Guideline (Fiore et al. 2000a) has
classified nortriptyline and clonidine as second-line treatments. Clonidine is an antihypertensive and may be appropriate for
patients addicted to certain types of drugs but
not appropriate for others. The antidepressant selective serotonin reuptake inhibitor
(SSRI) fluoxetine has been tested in a number
of multisite trials (Cook et al. 2004; Hitsman
et al. 1999; Niaura et al. 2002) and found to
have a small benefit at best, although for
patients who experience mild depressive
states it may be a worthwhile adjunctive
treatment. The usefulness of other SSRIs for
smoking cessation is unknown, but studies
have generally been unfavorable. More information on smoking cessation for people with
co-occurring substance use and other mental
disorders can be found in appendix D of TIP
42, Substance Abuse Treatment for Persons
With Co-Occurring Disorders (CSAT 2005c).
Combination drug therapy

Combining NRT products
NRT products typically provide less than half
the nicotine plasma levels that cigarette users
achieve through smoking (Benowitz et al. 1997;
Dale et al. 1995; Gupta et al. 1995; Lawson et
al. 1998). To attempt to increase nicotine lev-
els, several clinical trials have evaluated the

effectiveness of combining available products.
The simultaneous use of nicotine gum and the
nicotine patch has been evaluated in several
studies. Short-term gains in cessation were seen
with the combination compared to either medication alone, but no long-term benefits in abstinence were demonstrated (Anderson and
Wetter 1997). Blondal and colleagues (1999)
compared the combination of nicotine nasal
spray and the nicotine patch to the patch alone
and found that at 3 months 37 percent of the
patients were smoke free (compared to 25 percent for the patch alone). An open-label study
of the combined use of nicotine inhaler and the
nicotine patch found a 12-week cessation rate
of 30 percent and good tolerability for the combination (Westman et al. 2000).
So-called combination NRT involves combining different types of nicotine replacement
products, such as the patch and gum, on the
premise that doing so will boost nicotine
blood levels. Further rationale for this practice is that a passive nicotine delivery system (i.e., patch) produces relatively steady
levels of nicotine in the body that prevent the
user from going below a threshold minimum
while active NRTs (i.e., gum, inhaler,
spray, sublingual tablet, etc.) permit the user
to respond to situational cravings with ad libitum dosing on an acute basis. Several clinical
trials have evaluated the effectiveness of combining available NRT products (for a review
see Silagy et al. 2000). After reviewing available data, the Guideline panel (Fiore et al.
2000a) felt that there was moderately strong
evidence to conclude that Combining the
nicotine patch with a self-administered form
of nicotine replacement therapy (either the
nicotine gum or nicotine nasal spray) is more
efficacious than a single form of nicotine
replacement, and patients should be encouraged to use such combined treatments if they
are unable to quit using a single type of firstline pharmacotherapy (Fiore et al. 2000a, p.
77).
93
NRT using high-dose nicotine

patch therapy
The highest dose of nicotine available by patch
is 22mg. Several studies have evaluated
whether higher doses of nicotine (up to 44mg)
improve abstinence rates. The effect of this
strategy has been small and the routine use of
higher dose patches is not recommended
(Hughes et al. 1999; Killen et al. 1999).
Combining nicotine patch

and bupropion SR
In a double-blind, placebo-controlled study,
the combination of bupropion SR and the nicotine transdermal patch showed higher abstinence rates at 12 months (35.5 percent) compared to bupropion SR alone (30.3 percent),
nicotine patch alone (16.4 percent), or placebo
patch and pill group (15.6 percent) (Jorenby et
al. 1999). This combination was well tolerated.
Clinicians who use this combination should
first start the patient on bupropion SR 150mg
for 3 days and then increase the dosage to
150mg twice daily for 1 to 2 weeks prior to the
day of smoking cessation. On the quit day,
nicotine patch therapy should be initiated and
the combination treatment continued for 3 to 6
months (Okuyemi et al. 2000).

Most smokers attempt cessation on an outpatient basis and without any assistance from
professionals. However, if a patient decides
that she or he wants help with smoking cessation, it is important for the clinician to present
a supportive and nonjudgmental attitude and
develop a therapeutic alliance with the patient.
It must be emphasized that nicotine dependence is a chronic relapsing disorder and that
patients often make several attempts at quitting
before succeeding.
Most smokers who want treatment will seek
help from their primary care physician. The
physician has the responsibility of providing
pharmaceutical treatment, education about
common problems associated with cessation,
94
and emotional support to patients attempting

to quit. Discussing nicotine withdrawal symptoms can often help allay patient concerns.
Fear of weight gain is a barrier for many who
want to quit smoking (French et al. 1995).
This is an especially important issue for
women and may deter their attempts to stop
smoking (Gritz et al. 1989). Though the
health gains of stopping smoking clearly outweigh the health risks of weight gain, this
argument does little to assuage patients
fears. Dieting during smoking cessation is not
recommended in general and has been shown
to increase the likelihood of smoking relapse
(Hall et al. 1992). Physicians should, however, recommend both exercise and proper
nutrition for patients attempting to stop
smoking. Patients should be informed that
alcohol use also is considered a risk factor for
relapse to smoking by most clinicians
(Shiffman 1982), and patients who can
abstain from drinking during the withdrawal
period should do so.
Patients generally will find a smoke-free environment helpful during quit attempts. If the
patient lives in a household where others
smoke, household members and friends can
help by not smoking in front of the patient
and limiting the number of smoking cues in
their residence.
Patients with more severe nicotine dependence may benefit from enrollment in a specialized smoking cessation program. They
might also benefit from more intensive medical management using several drugs (NRT +
anticraving), medication for longer periods of
time, closer followup, and longer enrollment
in treatment. There are a number of cessation
programs available from organizations such
as the American Lung Association (www.
lungusa.org) and the American Cancer
Society (www.cancer.org). Some community
and local organizations also sponsor smoking
cessation programs. For the most severely
dependent smokers, there are a limited number of residential facilities that treat nicotine
dependence on an inpatient basis (Hurt et al.
1992). Providers of detoxification services
Chapter 4
should be familiar with the programs available in their communities in order to make
referrals.
Marijuana and Other

Drugs Containing THC
Marijuana and hashish are the two substances containing THC (delta-9-tetrahydrocannabinol) commonly used today. The field
of addiction medicine has given considerable
attention to the question of whether there is a
specific withdrawal syndrome associated with
cessation from prolonged THC use. In the
past, many have stated that there is no acute
abstinence syndrome that develops in people
who abruptly discontinue THC (CSAT
1995d). More recently this has been called
into question and most experts now believe
that a THC-specific withdrawal syndrome
does occur in some patients who are heavy
users (Budney et al. 2001), though cannabis
withdrawal is not yet included in the APAs
Diagnostic and Statistical Manual of Mental
Disorders.
The THC abstinence syndrome usually starts
within 24 hours of cessation. The amount of
THC that one needs to ingest in order to
experience withdrawal is unknown. It can be
assumed, however, that heavier consumption
is more likely to be associated with withdrawal symptoms. The most frequently seen symptoms of THC withdrawal are anxiety, restlessness and irritability, sleep disturbance, and
change in appetite (usually anorexia). Other
symptoms of withdrawal are less frequently
seen and appear to include tremor, diaphoresis (sweating), tachycardia (elevated heart
rate), and GI disturbances, including nausea,
vomiting, and diarrhea. Cognitive difficulties
including depression also have been reported
and may persist but usually improve with
time. There are no medical complications of
withdrawal from THC, and medication is generally not required to manage withdrawal.
Clinicians may see a variety of the symptoms
mentioned above, but these generally require
no immediate medication during the detoxification period and usually are self-limiting.
However, the clinician should be aware of the
potential for more persistent problems.
Screening the patient for suicidal ideation or
other mental health
problems is warrantMost experts now
ed. Some reviews
have advocated the
use of buspirone as
believe that a
an alternative to
benzodiazepines for
THC-specific withthe management of
persistent generaldrawal syndrome
ized anxiety (Gatch
and Lal 1998). Other
does occur in some
common problems
encountered during
patients who are
withdrawal can be
managed with nonadheavy users,
dictive, supportive
medications. For
though cannabis
patients with more
persistent difficulty
sleeping, clinical
withdrawal is not
experience suggests
that Trazodone may
yet included in the
be useful. Trazodone
can lead to low blood
APAs Diagnostic
pressure upon standing, dizziness, and
and Statistical
may increase falls,
particularly in indiManual of
viduals over age 60.
Benzodiazepines and
Mental Disorders.
other addictive medications should be
avoided.
The patient should be encouraged to maintain
abstinence from THC as well as other addictive substances. Some patients will require a
substance-free, supportive environment to
achieve and maintain abstinence. Clinicians
should educate all patients about the effects
of withdrawal, validate their complaints, and
reassure them that their symptoms will likely
improve with time. Symptomatic relief may be
provided in order to increase the patients
comfort.
95
There are no clinical assessment instruments

available that measure THC withdrawal.
Both animal and human studies indicate that
a withdrawal syndrome starts within 24 hours
of cessation and may last for up to a week.
Anabolic Steroids
Anabolic steroids, as differentiated from corticosteroids and female gonadotropic hormones, are androgens (male hormones) and
subject to abuse as a means of increasing
muscle mass. These
agents also can produce aggressive,
Interventions
manic-like behavior
that may include
directed toward
delusions (Lukas
1998). Males
cessation should
involved in professional sports,
involve patient
weight lifting, body
building, or other
education regarding
pursuits that value
muscular mass are
the dangers and
more likely to use
these substances
medical complicathan are women,
although use in
tions of anabolic
women has been
reported.
steroids, their
Adolescents use
anabolic steroids to
behavioral effects,
improve their
appearance and
and a thorough
may have increased
access to these comevaluation of the
pounds (Yesalis et
al. 1993). The large
patients rationale
numbers of anabolic steroid preparafor misuse.
tions that have
medical and veterinary uses are primarily obtained illegally through diversion.
High doses of anabolic steroids can be medically dangerous but side effects, usually
involving endocrine, liver, central nervous
system, and cardiac function, tend to be
reversible upon cessation of anabolic steroid
96
use. However, neither cessation nor disclosure of anabolic steroid use can be assumed
when treating these individuals.
Withdrawal Symptoms
Associated With Steroids
Anabolic steroids can be associated with withdrawal symptoms emerging after their abrupt
discontinuation. Withdrawal symptoms
include (in descending order of prevalence)
craving for more steroids, fatigue, depression, restlessness, anorexia (loss of appetite),
insomnia, reduced libido (sex drive),
headaches, and nausea (Lukas 1998). It is not
known how commonly this syndrome occurs,
but steroid withdrawal appears more likely in
heavy users. The clinicians index of suspicion should be raised when evaluating individuals who are predisposed to steroid misuse
and who exhibit these symptoms. Also indicative of possible steroid abuse are certain
physiological signs of androgen exposure,
including hair loss, acne, dysuria (difficult or
painful urination), small testicles, edema of
the extremities, and rapid weight gain.
Females can develop decreased breast size,
acne, virilism (clitoral enlargement, excessive
and abnormal bodily hair growth, male pattern baldness) and amenorrhea (suppression
of menstruation). Males who abuse steroids
have been reported to possess a distorted
body image and may inaccurately view themselves as small and weak (Pope et al. 1993).
Steroid Withdrawal
Due to anabolic steroids long duration of
action, side effects that might emerge cannot
be quickly reversed by the discontinuation of
these substances. Therefore, related side
effects might require medical management
beyond the simple recommendation that
steroids immediately be discontinued.
Persistent side effects include urinary tract
infections, bladder irritability, skin blistering
(at the injection site), erythema (abnormal
skin redness) when given as a skin patch, and
Chapter 4
priapism (prolonged erections lasting hours).

The latter condition involves a painful penile
erection and constitutes an emergency that
requires specialized medical attention. Edema
(swelling) of the hands or feet, commonly seen
with anabolic steroids, can be treated with
diuretics (medications that increase urine
flow). Elevated liver function tests and jaundice usually resolve with cessation of anabolic
steroid administration, although hepatic carcinoma (cancer of the liver) has been reported. Other side effects such as headache, nausea, vomiting, acne, insomnia, and lethargy
are time-limited and resolve after steroid cessation. Behavioral disturbances, such as psychosis or severe aggressiveness, should be
treated symptomatically with appropriate
psychopharmacological interventions. In
extreme cases of psychotic or manic presentations, emergency psychiatric hospitalization
might be necessary to address dangerousness
to self or others.
Management of Steroid
Withdrawal
There is no recommended detoxification protocol for anabolic steroids. The key medical
goal is that of persuading the patient to cease
steroid misuse. This intervention should be
followed by evaluating and treating any side
effects (discussed above) that might be present. Interventions directed toward cessation
should involve patient education regarding
the dangers and medical complications of
anabolic steroids, their behavioral effects,
and a thorough evaluation of the patients
rationale for misuse. A family meeting often is
helpful if agreed upon by the patient.
Unfortunately, education alone often is insufficient. Patients with distorted body images
might be especially difficult to dissuade from
steroid misuse, and referral to psychotherapy
by a qualified clinician trained in the treatment of body image disorder should be considered. Similarly, patients who derive significant muscle gain from anabolic steroids might
be resistant to cessation and may conceal continued steroid use.

Patient comfort during steroid withdrawal can
be achieved by addressing side effects, if present, that are discussed above. Counseling also
is a useful intervention and specialized psychiatric interventions may be necessary. If the
individual also is using other substances of
abuse, referral to drug or alcohol rehabilitative
treatment should be made.
Club Drugs
Club drugs represent diverse classes of drugs
that include sedative-hypnotic type agents as
well as stimulant/hallucinogens. Club drugs are
illicit drugs used in the setting of nightclubs,
dance clubs, parties, and raves. Raves are
overnight dance parties, usually with several
hundred people in attendance.
Abuse of these drugs by adolescents and
young adults has risen greatly in recent years.
All healthcare professionals need familiarity
with their short- and long-term effects.
Although withdrawal syndromes have been
reported with some of these drugs, this is not
the most common clinical problem.
Intoxication and severe intoxication with
overdose are more frequent problems. With
some of these compounds, there appears to be
the potential for neurotoxicity (destructive
effects on the nervous system) and persistent
psychiatric and neurologic syndromes. At the
present time, much of the available information regarding club drugs comes from surveys
and anecdotal case reports. Human laboratory studies and rigorously controlled clinical
trials are not common.
One difficulty in assessing the effects of intoxication, overdose, withdrawal, and long-term
health consequences of club drugs is that in
general, there are no baseline evaluations of
individuals before they used club drugs. Also,
these individuals abuse more than one substance. Some of these patients may have had
moderate to severe psychopathology (including psychosis) prior to their introduction to
club drugs. In the past, some club drugs were
97
referred to as designer drugs because of

their production in a laboratory rather than
being processed from plant products.
Hallucinogens
Hallucinogens are a broad group of substances that can produce sensory abnormalities and hallucinations. Most hallucinogens
have some adrenergic effects as well.
Hallucinogens also are referred to as
psychedelics and psychomimetics. The more
traditional hallucinogens such as lysergic acid
diethylamide (LSD) are considered primarily
serotonergic-acting agents. Some of the other
compounds include phenylethylamines which
have hallucinogenic properties but act like
amphetamines as well. These drugs include
mescaline and MDMA (3,4-methylenedioxy-Nmethylamphetamine). Other drugs include
MDA (3,4-methylenedioxyamphetamine) and
DOM (dimethyloxymethylamphetamine). (See
section on ecstasy below.) Other hallucinogens
are acetylcholine antagonists. These include
belladonna, drugs such as benzotrophine
used to treat parkinsonian symptoms, and
many common over-the-counter antihistamines.
Hallucinogen intoxication often begins with
autonomic effects, sometimes nausea and
vomiting, and mild increases of heart rate,
body temperature, and slight elevations of
systolic blood pressure. Dizziness and dilated
pupils may occur. The prominent effects during intoxication are sensory distortions with
illusions and hallucinations. Visual distortions are more common than auditory or tactile ones. So-called bad trips may involve
anxiety including panic attacks, paranoid
reactions, anger, violence, and impulsivity.
Either due to delusions or misperceptions,
individuals may feel they can fly or have special powers, and thus injure themselves in
falls or other accidents. Suicide attempts also
can occur during bad trips and possible
suicidal ideation should be carefully evaluated, even though it may be quite transient.
98
Withdrawal syndromes have not been reported with hallucinogens; however, considerable
attention has been paid to residual effects
such as delayed perceptual illusions with anxiety, flashbacks, residual psychotic symptoms, and long-term cognitive impairment.
Controversies around these issues are not
important in the clinical setting. The important thing is to determine whether residual
symptoms are present and provide an appropriate environment and appropriate care for
the individual who has them. Generally, staff
of emergency rooms, clinics that treat people
who abuse substances, and social detoxification centers have individuals who are very
familiar with talking down individuals with
bad hallucinogenic trips.
Acute intoxication and bad trips usually can
be managed with placement of the individual
in a quiet, nonstimulating environment with
immediate and direct supervision so that the
patient does not cause harm to herself or to
others. Occasionally, a low dose of a short- or
intermediate-acting benzodiazepine may be
useful to control anxiety and promote sedation. Individuals with chronic depressive-like
reactions may require antidepressant therapy. Individuals with residual psychotic symptoms are likely to require antipsychotic medications. On rare occasions, the use of a low
dose, high-potency antipsychotic medication
may be required orally or parenterally (any
method other than the digestive tract, e.g.,
intravenously, subcutaneously, or intramuscularly). Assessment of residual psychiatric
and cognitive symptoms should be made prior
to treatment referral.
Gamma-hydroxybutyrate
(GHB)
GHB use has increasingly been reported in
night clubs and at raves by adolescents and
young adult populations. GHB is a compound
that is produced in the central nervous system, and it acts as an inhibiting neurotransmitter similar to GABA (Shannon and Quang
2000). In pharmacologic (medication-propor-
Chapter 4
tioned) doses, GHB serves as a sedative-hypnotic medication. GHB intoxication may look
like alcohol or sedative-hypnotic intoxication.
Although GHB is illegal, psychotropic compounds similar to GHB such as gammahydroxy lactone (GBL) and 1,4-butanediol
(1,4-BD) are widely available chemical compounds and may be obtained through catalogs
and the Internet. These compounds produce
effects similar to those of GHB. At the present, overdose syndromes are more likely to
be seen than withdrawal syndromes.
Overdose syndromes may require airway and
respiratory management. GHB has been studied in Europe (Addolorato et al. 1999a) in a
randomized, single-blind study comparing it
to diazepam as a treatment for alcohol withdrawal. GHB was as effective as diazepam in
suppressing alcohol withdrawal symptoms
and was said to be quicker in reducing anxiety and agitation with less sedation than
diazepam. Because of its history of abuse in
the United States, it is unlikely to be viewed
as a therapeutic agent any time in the near
future.
Miotto and Roth (2001) describe a GHB withdrawal syndrome, noting that it shares features of both alcohol and benzodiazepine
withdrawal. They have found this syndrome
most pronounced in patients who have taken
GHB around-the-clock, at 2- to 4-hour intervals. The GHB withdrawal syndrome has the
prolonged duration of symptoms found in
benzodiazepine withdrawal and features
delirium tremens that appear early (often
within an hour) with peak manifestations
occurring within 24 hours; the delirium may
last up to 14 days. Confusion, psychosis, and
delirium are the most prominent features of
GHB withdrawal, and the autonomic effects
(i.e., tremor, diaphoresis [sweating], hypertension, and temperature changes) are less
severe than found in alcohol withdrawal.
They note that brief periods of significant
tachycardia (rapid heart rate) begin early in
GHB withdrawal. Garvey and Fitzmaurice
(2004) also report seizure activity in a case of
GHB withdrawal in a male who had been
using the substance regularly over a 2-year

period, and Rosenberg and colleagues (2003)
note that in severe cases GHB withdrawal
may be life-threatening.
Milder cases of GHB withdrawal syndrome
may be managed with benzodiazepines such
as lorazepam and supportive care. However,
in more severe cases high doses of intravenous benzodiazepines (e.g.,
Withdrawal
lorazepam) or barbiturates (e.g., phenosyndromes have not
barbital, pentobarbital) may be
been reported with
required (Miotto
and Roth 2001;
hallucinogens;
Rosenberg et al.
2003). Patients
however, considerexperiencing GHB
withdrawal are likeable attention has
ly to have a high tolerance for the sedabeen paid to
tive effects of benzodiazepines and
residual effects such
require large and
frequent doses to
as delayed
manage the withdrawal (Miotto and
perceptual illusions
Roth 2001); in cases
where high doses of
with anxiety,
lorazepam prove
ineffective, pentoflashbacks,
barbital may be
effective (Sivilotti et
residual psychotic
al. 2001). Clonidine
may be used to treat
symptoms, and
episodes of tachycardia (rapid heart
long-term cognitive
rate) (Miotto and
Roth 2001).
impairment.
Ecstasy
MDMA (3, 4-methylenedioxy-methamphetamine) commonly known as ecstasy, was
synthesized around the turn of the century and
patented by Merck Pharmaceuticals in 1914
(Christophersen 2000; Parrot et al. 2000).
These drugs are phenel-ethylene stimulants
99
with various substitution groups off the benzene ring that give the medications hallucinogenic properties. There are a number of related compounds that are designated by their initials (MDMA, MDA, MDEA, DOM, 2-CB, and
DOT). Clinicians are likely to have to manage
the complications of intoxication and overdose
but not withdrawal.
Patients using MDMA or related compounds
frequently are hyperactive and hyperverbal,
reporting heightened tactile and visual sensations. They frequently will use camphor on
the skin in facial masks, gloves, and other
clothing to heighten their tactile sensations.
Sometimes light sticks are used to heighten
visual experiences at raves. Hyperthermia,
dehydration, water intoxication with low sodium, rhabdomyolysis (severe muscular injury
and breakdown of muscle fibers), renal failure, cardiac arrhythmia, and coma have been
reported.
MDMA has been proven to be toxic to serotonergic neurons in several animal studies.
Heavy ecstasy users can have paranoid thinking, psychotic symptoms, obsessional thinking, and anxiety (Parrott et al. 2000).
Impaired cognitive performance in heavy
ecstasy users also has been identified
(Gouzoulis-Mayfrank et al. 2000). Ecstasy
users performed more poorly than control
groups in complex attention, memory, and
learning tasks. The duration or permanence
of such effects has not yet been well studied.
Ketamine and PCP

(Phencyclidine)
Ketamine and PCP (phencyclidine) were both
developed in the 1950s as anesthetic agents for
humans. Phencyclidine was briefly marketed
for human anesthetic use but taken off the
market because of an unusual high incidence of
psychotic symptoms. PCP remains in legitimate
use for veterinarian anesthesia for large animals as does ketamine for small animals.
Although both drugs were originally developed
for intravenous use, they are now manufac-
100
tured illicitly as oral drugs of abuse. PCP frequently is sold as LSD.

Some studies have found that ketamine and
PCP act specifically at the MDMA/glutamate
receptor as noncompetitive MDMA receptor
antagonists. Research in animals indicates
that both drugs are reinforcing, in that animals will press a bar to obtain doses of either
drug. Furthermore, in these same animal
models, abstinence syndromes have been
observed. Withdrawal symptoms in humans
have included depression, drug craving,
increased appetite, and hypersomnolence
(excessive sleep).
In the clinical setting, syndromes of acute
intoxication with hallucinations, delusions,
agitation, and violence are the most pressing
problems. A human laboratory study (Lahti
et al. 2001) conducted a comparison of
ketamine and placebo in normal volunteers
never exposed to ketamine and to people with
schizophrenia with a previous history of
ketamine use. In both groups, ketamine produced a dose-related, but brief, increase in
psychotic symptoms. The magnitude of
ketamine-induced positive psychotic symptoms was similar for both groups, although
the schizophrenia group had higher baseline
scores.
Although originally MDMA receptor antagonists were felt to have neuroprotective effects
(preventing damage to brain cells) and have
been explored as post-stroke medications,
there is some evidence now that ketamine and
PCP may in fact have some neurotoxic
effects. Studies (e.g., Curran and Monaghan
2001) have found greater memory impairment
among chronic ketamine users than infrequent ketamine users. Acute human laboratory studies by this group indicate persistent
memory impairment with ketamine exposure.
This same study did not find persistent psychotic features beyond acute use.
In the clinical setting, ketamine and PCP use
require management for the agitation and
psychotic features produced during acute use.
Occasionally, patients will have such large
Chapter 4
overdoses, intentionally or accidentally, that

they will require airway management and
ventilatory support for some hours. The
behavioral management of the agitation and
violence that may be seen is best managed in
a controlled environment with limited stimuli
and very close supervision. Occasionally, oral
or parenteral uses of sedating medications
such as benzodiazepines will be required. In
extreme cases, restraints may be required for
protection of the patient and staff.
Following acute management, assessment of
persistent mood and cognitive effects must be
made prior to any treatment attempts. The
persistence of psychotic symptoms may represent an underlying psychiatric disorder that
may require medication treatment. There are
no studies to guide the treatment of ketamine
or PCP detoxification. The need to manage
withdrawal symptoms from these drugs is
unlikely, but if it should arise, benzodiazepines should be administered.
Other
Rohypnol is a benzodiazepine that is sold
under trade names in Europe and Mexico as a
sedative-hypnotic. Rohypnol is occasionally
used as a club drug and at dance clubs. In the
last decade it began to be smuggled into the
United States and was commonly used among
homeless youth involved in the sex industry.
Rohypnol has a reputation as a date rape
drug because it can produce powerful amnestic
and hypnotic effects, as well as coma. For further details on benzodiazepines, see the benzodiazepine section regarding intoxication and
potential withdrawal reactions.
Management of
Polydrug Abuse: An
Integrated Approach
One of the most significant changes in detoxification services in recent years has been the
increase in the number of patients requiring
detoxification from more than one substance.
In an evaluation of admissions to publicly

funded detoxification programs in
Massachusetts between 1984 and 1996,
McCarty and colleagues (2000) found a steady
increase in the number of patients using both
alcohol and other substances in the month
prior to admission. In 1988, 26 percent of
admissions reported using two or more substances in the previous month; by 1996 that
number had nearly
doubled to 50 percent (McCarty et al.
2000). There is no
One of the most
reason to believe that
this trend has not
significant changes
appeared elsewhere
in this country. As
in detoxification
Miller and colleagues
(1990a) note, For
services in recent
the contemporary
drug addict, multiple
years has been the
drug use and addiction that includes
increase in the
alcohol is the rule
(p. 597).
number of
In the Massachusetts
evaluation, which
patients requiring
did not include marijuana or nonopioid
detoxification
prescription medication use, the most
from more than
commonly seen combination of subone substance.
stances was alcohol
and cocaine. Thirty
percent of patients
admitted for detoxification in 1996 reported using this combination; 12 percent used alcohol, cocaine, and
heroin together; 10 percent combined alcohol
and cocaine; and 7 percent combined heroin
and cocaine (McCarty et al. 2000). Other
studies, evaluating patient populations at
inpatient treatment centers, found that
between 70 and 90 percent of patients who
reported cocaine abuse also abused alcohol.
Rates of alcohol dependence among
methadone patients and patients dependent
on heroin were between 50 and 75 percent,
101
An Example of Potential Problems:

Detoxification for Polydrug Abuse
Mr. L is a 43-year-old male with a 25-year heroin dependence. He is well known to the detoxification center,
having been through the program there (which consisted primarily of support and hydration) on many
occasions over the years. Though he looked more gaunt and, not surprisingly, a bit more ill each time he
arrived, his course usually was about the same: 2 or 3 days of serious stomach cramps, nausea, and diarrhea, then a few days of feeling poorly, and then a return to the community. This time, however, was different. He looked sicker than usual. Mr. L usually was a compliant patient; now he was hostile and belligerent. He seemed to be talking to himself and did not seem as alert as he should have been. The staff asked
him several times if he had used anything else and each time he denied it. His drug of choice was always
heroinhe drank alcohol once in a while, and occasionally smoked marijuana when he could not get anything else. On the third day of detoxification, Mr. L seemed acutely more ill. On his way to the bathroom he
was observed staggering, and as he reached for the door he fell, striking his head, and suffered a grand mal
seizure. At the local hospital, a toxicological screen showed the presence of PCP, high levels of barbiturates,
opioids, and trace amounts of benzodiazepines
and 80 to 90 percent who were being treated
for cannabis abuse also reported alcohol
abuse (Miller et al. 1990a).
Clinicians need to be constantly aware that a
patient may be abusing multiple substances.
Even if a patient admits the abuse of one substance he may not admit to using others.
Patients may not see that other substances
are a problem, they may be worried about the
legal consequences of use, or they sometimes
may not even be aware of what substances
they have been using. For these reasons, clinicians should not rely on patients self-reports
to determine which substances are being
used. Interviews with family, friends, or others who know the patient may be helpful, but
these also are insufficient. The consensus
panel strongly recommends that all patients
receive an immediate urine drug screening
upon admission to a detoxification program to
determine the types of substances being
abused. It is not necessarily true that the person is drug free simply because a drug is not
detected on a drug screen. It is possible that
the toxicology is not able to detect the class or
type of drug. Staff should be aware of what
the program/detoxification center/hospital
tests for, what is not tested for, what cannot
be tested for or found, and the limitations of
dip tests.
102
Prioritizing Substances of
Abuse
While substances of abuse may have complex
interactions, it is not always possible to determine how those interactions will affect withdrawal. Therefore, it is generally best practice
to prioritize the substances an individual has
been dependent on and treat them sequentially
according to the severity of the withdrawal produced by the substance. The substances with
the most serious withdrawal syndromes, those
where the withdrawal syndrome can be fatal,
are alcohol and the sedative-hypnotics. When
detoxifying a patient who has been dependent
upon multiple substances, the sedative-hypnotics must be addressed first.
Oral methadone, LAAM, or buprenorphine
should be used to stabilize withdrawal from
opioids while tapering the dose of the sedative-hypnotic or anxiolytic (anti-anxiety medication) by 10 percent each day. After the
patient has been tapered off of the sedativehypnotic or anxiolytic, withdrawal from the
substitute opioid can begin (Wilkins et al.
1998). Some patients can successfully be
detoxified from both sedative-hypnotics and
opioids simultaneously, but this requires a
great deal of medical and nursing attention.
Most patients will benefit from opioid mainteChapter 4
nance for an extended period of time following the completion of sedative withdrawal.
If the patient has been abusing multiple sedative-hypnotic substances or a sedative-hypnotic
and alcohol, withdrawal should be handled in
the same way as withdrawal from one such substance. The patient should be administered a
regularly decreasing dosage of sedative-hypnotic, usually a benzodiazepine that the clinician is
comfortable with and accustomed to using. The
dosage should be decreased according to the
patients physiologic response. Providers also
may administer an anticonvulsant such as carbamazepine (Tegretol XR), even in the absence
of epilepsy or withdrawal seizures, to help
ensure patient safety (Wilkins et al. 1998).
Phenobarbital also may be used for detoxifying
patients who have been abusing both alcohol
and benzodiazepines. When the dose of alcohol
and sedative-hypnotics that a patient is taking
is not known, tolerance testing as previously
described can be helpful in determining the
dose of phenobarbital.
When treating patients detoxifying from substances other than sedative-hypnotics, management of opioid detoxification should be the next
priority. Generally, other substances of abuse,
including stimulants, marijuana, hallucinogenics (LSD and similar drugs), and inhalants, will
not require specific treatment in patients who
are being detoxified from sedative-hypnotics
and/or opioids.
Patients may abuse a wide range of substances
in various combinations, and the clinician must
be vigilant in assessing and treating withdrawal
from multiple substances. The case study above
illustrates some of the serious problems the
clinician faces in evaluating and treating
patients withdrawing from multiple substances.
In the private sector, where money for toxicological screening is readily available, the first
question many would ask concerning the case
of Mr. L. is, Why wasnt the drug screen done
sooner? However, those working in public
facilities will recognize that such screenings
often are unavailable or available only after an
extended turnaround time. Toxicological
screening, even a hand-held screening, can be

an expensive item for what often is a very limited budget. Besides, in this case, the patient was
believed to be a known quantitysomeone who
only used heroin.
This scenario is not uncommon. It is likely that
the patient himself was unaware of what was in
his body. One of the more frightening facts concerning the purchase of illicit drugs is the lack
of knowledge of what is in them. To make buyers believe that they are buying a higher-quality product than they are, drugs often are cut
with adulterants (inferior ingredients) that can
produce effects similar to the drug they think
they are buying. In this case, Mr. L may have
been buying barbiturates and benzodiazepines
in his heroin for some time without knowing it,
a fact that could have had deadly consequences. Both are sedating and could have
given him some of the comfortable sedation and
euphoria he was seeking from his drug of
choice. Unfortunately, however, where opioid
withdrawal is not life-threatening, withdrawal
from barbiturates can be. Furthermore, he
could have gotten PCP in the marijuana he
occasionally used, again without knowing it.
Alternative
Approaches
Alternative methods that have been studied scientifically do not claim to be stand-alone withdrawal methods, nor stand-alone treatment
modalities. Alternative approaches are
designed to be used in a comprehensive, integrated substance abuse treatment system that
promotes health and well-being, provides palliative symptom relief, and improves treatment
retention. Therefore, because isolation of any
of these approaches as an independent variable
in rigorous controlled studies is difficult, if not
impossible, there are no conclusive data on the
effectiveness of alternative methods
(Trachtenberg 2000).
Auricular (ear) acupuncture has been used
throughout the world, beginning in Hong Kong,
as an adjunctive treatment during opioid
103
detoxification for about 30 years. Its use in the

United States originated in California
(Seymour and Smith 1987) and New York
(Mitchell 1995) but has not been subjected to
rigorous controlled research. One report
(Washburn et al. 1993) noted that patients
dependent on heroin with mild habits appeared
to benefit more than those with severe withdrawal symptoms, which acupuncture did not
alleviate. The 1997 National Institute of Health
Consensus Statement on acupuncture stated
that acupuncture treatment for addiction could
be part of a comprehensive management program. The National Acupuncture
Detoxification Association has developed
acupuncture protocols involving ear acupuncture in group settings that originated at Lincoln
Hospital in the Bronx and are used by over 400
drug treatment programs and 40 percent of
drug courts. SAMHSAs National Survey of
Substance Abuse Treatment Services (NSSATS)
found that 5.4 percent of the 13,720 facilities
polled in 2001 offered acupuncture as a service
(Office of Applied Studies 2002b).
Acupuncture is one of the more widely used
alternative therapies within the context of
addictions treatment. It has been used as an
adjunct to conventional treatment because it
seems to reduce the craving for a variety of
substances of abuse and appears to contribute to improved treatment retention rates.
In particular, acupuncture has been viewed
as an effective adjunct to treatment for alcohol and cocaine disorders, and it also has
played an important role in opioid treatment
(i.e., methadone maintenance). It is used as
an adjunct during maintenance, such as when
tapering methadone doses. The ritualistic
aspect of the practice of acupuncture as part
of a comprehensive treatment program provides a stable, comfortable, and consistent
environment in which the client can actively
participate. As a result, acupuncture
enhances the clients sense of engagement in
the treatment process. This may, in part,
account for reported improvements in treatment retention (Boucher et al. 2003). A 1999
CSAT-funded study showed that patients
104
choosing outpatient programs with acupuncture were less likely to relapse in the 6
months following discharge than were patients
who had chosen residential programs
(Shwartz et al. 1999).
Ear acupuncture detoxification, which was
originally developed as an alternative treatment for opioid agonist pharmacotherapy, is
now augmenting pharmacotherapy treatment
for patients with coexisting cocaine problems
(Avants et al. 2000). The advocates of
acupuncture have joined with the advocates
of opioid agonist pharmacotherapy to create a
holistic synthesis. Each has contributed to the
success of the other, both clinically and in
public perception.
Care must be taken to ensure sterile acupuncture needles in the heroin-dependent population, given the high incidence of HIV infection, viral hepatitis, and other infections.
Acupuncture is not recommended as a standalone treatment for opioid withdrawal.
Other alternative management approaches
that are not supported by controlled studies
include neuroelectric therapy (the administration of electric current through the skin)
and herbal therapy. In fact, the former has
been shown to be no better than placebo in a
controlled study (Gariti et al. 1992). The use
of herbs for healing purposes dates back to
the dawn of civilization, while the use of
herbs in the treatment of substance abuse has
been documented since 1981 in methadone
programs, free clinics, therapeutic communities, outpatient programs, and hospitals
(Nebelkopf 1981). Herbal remedies are used
in substance abuse detoxification and treatment in a number of cultures around the
world. However, in no scientific studies have
herbs been isolated as a discrete variable to
test their efficacy. Much research is currently
being conducted on the effectiveness of herbal
medicine on a wide variety of physical
conditions.
Chapter 4
Considerations for
Specific Populations
All individuals undergoing detoxification are
especially vulnerable. Patients who experience
negative attitudes from staff may experience
further loss of self-esteem, may leave detoxification prematurely, or may experience other
psychologically damaging feelings. Negative
experiences can undermine the recovery process. It is important to recognize that individuals do not fit into just one population category.
A person will be a member of several populations (e.g., a Latina woman who is pregnant,
bisexual, and has psychiatric diagnoses of posttraumatic stress disorder and major depression) and may benefit from a number of the
considerations discussed below. It also should
be noted that the information in the specific
populations sections should not be used to categorize individuals or leave the reader with the
impression that the information below will fit
all individuals who are members of a group.
Pregnant Women
While in detoxification, pregnant women
should receive comprehensive medical care,
especially since this may be the first time they
have sought any type of care or treatment.
Ideally, programs detoxifying pregnant women
from alcohol and illicit drugs should include
the following services:
Detoxification on demand
Woman-centered medical services
Transportation services to and from detoxification (as well as to substance abuse treatment afterward)
Childcare services
Counseling and case management services
Access to drug-free, safe, affordable housing
Help with legal, nutritional, and other social
service needs
While it is recognized that provision of all of
these services is an ideal to be striven for, at a
minimum detoxification programs must have
strong linkages to agencies that provide the

above-mentioned services and should set up
systems to ensure that pregnant women can
access the additional services they need.
Pregnant women who present for detoxification
will benefit from a comprehensive medical
examination that includes a careful obstetrical
component. Since it is estimated that approximately 44 to 70 percent of women who abuse
substances have a history of physical, emotional, and sexual
Pregnant women
abuse (Moylan et al.
2001; Stevens et al.
who present for
1997), care should be
given to the comfort
detoxification will
of the patients during
the examination. One
benefit from a
of the major internal
barriers that prevents
comprehensive
pregnant women from
seeking treatment is
the shame and stigma
medical examinaattached to substance
use, especially during
tion that includes
pregnancy. Any negative experience
a careful
encountered during
detoxification can
obstetrical
lead these women to
leave treatment and
component.
not return.
Detoxification during
pregnancy poses a
special risk in that
care should be taken
to ensure the health and safety of both the
mother and fetus. From a clinical standpoint,
before giving any medications to pregnant
women it is of vital importance that they
understand the risks and benefits of taking
these medications and sign informed consent
forms verifying that they have received and
understand the information provided to them.
Since pregnant women often present to treatment in mid- to late-second trimester and polydrug use is the norm rather than the exception
(Jones et al. 1999), it is important first to
105
screen these women for dependence on the two

classes of substances that can produce a lifethreatening withdrawal: alcohol and sedativehypnotics. Pregnant women should be made
aware of all wraparound services that will
assist them in dealing with newborn issues,
including food, shelter, medical clinics for inoculations, as well as programs that will help with
developmental or physical issues that the
neonate (newborn baby) may experience as a
result of substance
exposure.
A National
Alcohol
Institutes of
When pregnant
women are detoxified from alcohol,
Health consensus
benzodiazepine
tapers appear to be
panel
the current practice
of choice. The currecommended
rent state of knowledge suggests that
methadone
benzodiazepine
therapy in general
maintenance as
does not have as
much of a teratothe standard of
genic (producing a
deformed baby) risk
care for pregnant
as do other anticonvulsants as long as
they are given over
women with
a short time period.
It appears that
opioid
short-acting benzodiazepines, like the
dependence.
ones described to
treat alcohol withdrawal above, can
be used in low doses for acute uses such as
detoxification, even in the first trimester
(Robert et al. 2001). Long-acting benzodiazepines should be avoidedtheir use during
the third trimester or near delivery can result
in a withdrawal syndrome in the baby (Garbis
and McElhatton 2001).
Although no teratogenic effects have been
observed, little is known about the effects of
106
naltrexone, naloxone, or nalmefene administration during pregnancy. Although propranolol (Inderal), labetalol (Trandate), and
metoprolol (Lopressor) are the beta blockers
of choice for treating hypertension (high
blood pressure) during pregnancy
(McElhatton 2001), the impact of using them
for alcohol detoxification during pregnancy is
unclear. The use of SSRIs, a class of antidepressant medication, is safer for the mother
and fetus than are tricyclic antidepressants
(Garbis and McElhatton 2001). Fluoxetine
(Prozac) is the most studied SSRI in pregnancy and no increased incidence in malformations was noted, nor were there neurodevelopmental effects observed in preschool-age
children (Garbis and McElhatton 2001).
However, possible neonatal withdrawal signs
have been observed. Given that the greatest
amount of data are available for fluoxetine,
this is the recommended SSRI for use during
pregnancy (Garbis and McElhatton 2001).
The use of anticonvulsants, such as valproic
acid, is associated with several disfiguring
malformations. If this type of medication
must be used during pregnancy, the woman
must be told that there is substantial risk of
malformations (Robert et al. 2001).
Barbiturate use during pregnancy has been
studied to some extent, and phenobarbital is
used therapeutically during pregnancy, but
the risk of any anticonvulsive medication
should be discussed with the patient (Robert
et al. 2001). There also are reports of a withdrawal syndrome in the neonate following
prenatal exposure to phenobarbital (Kuhnz et
al. 1988).
Opioids
While it is not recommended that pregnant
women who are maintained on methadone
undergo detoxification, if these women
require detoxification, the safest time to
detoxify them is during the second trimester.
For further information, consult the forthcoming TIP Substance Abuse Treatment:
Addressing the Specific Needs of Women
(CSAT in development e) and TIP 43
Chapter 4

(CSAT 2005d). In contrast, it is possible to
detoxify women dependent on heroin who are
abusing illicit opioids by using a methadone
taper.
Before starting a detoxification, women
should weigh the risks and benefits of detoxification, since many women eventually
relapse to drug use and thus place themselves
and their fetuses at risk for adverse consequences (Jones et al. 2001b). During pregnancy, the protein binding of many drugs, including methadone and diazepam (a benzodiazepine), is decreased (e.g., Adams and
Wacher 1968; Dean et al. 1980; Ganrot 1972)
with the greatest decrease noted during the
third trimester (Perucca and Crema 1982).
This decreased binding may be due to the
decreased levels of albumin reported during
pregnancy (Yoshikawa et al. 1984). From a
clinical standpoint, it may be that pregnant
women could be at risk for developing greater
toxicity and side effects, yet at the same time
an increase in metabolism of the drug may
result (such as found with methadone). This
may result in reduced therapeutic effect from
the drug, since many women require an
increase in their dose of methadone during
the last trimester (Pond et al. 1985).
Other medications used to treat the withdrawal signs and symptoms include clonidine.
Clonidine is used as a second-line drug to
treat hypertension (high blood pressure) during pregnancy and appears to lack teratogenic
effects (McElhatton 2001). It has reportedly
been abused by pregnant women. Some pregnant women take clonidine with their
methadone because it is hard to detect in
urine and it increases the high they get from
methadone. However, little is known about its
effects on the baby following therapeutic
doses given in a detoxification context or
doses taken in higher than therapeutic
amounts (Anderson et al. 1997a).
Buprenorphine has been examined in pregnancy and appears to lack teratogenic effects
but may be associated with a withdrawal syndrome in the neonate (Jones and Johnson
2001).
A National Institutes of Health consensus
panel recommended methadone maintenance
as the standard of care for pregnant women
with opioid dependence. Methadone currently
is the only medication recommended for medication-assisted treatment for pregnant
women. Clinical trials are being conducted to
determine the efficacy and safety of
buprenorphine with pregnant women but it
has not yet been approved for use with this
population. Two early studies on treatment of
pregnant women with opioid dependence with
buprenorphine showed promising results
(Fischer et al. 2000; Johnson et al. 2001).
Comer and Annitto (2004) conclude, from
their review of the research literature, that
buprenorphine should be used more aggressively to detoxify pregnant women who want
to be opioid-free at delivery.
Because of the potential for premature labor
and delivery and risks of morbidity and mortality to the fetus related to withdrawal from
opioids, it is recommended that a pregnant
woman who is dependent on opioids be maintained during pregnancy (Kaltenbach et al.
1998). Other reasons to stabilize a pregnant
woman on methadone rather than attempt
withdrawal are the risks of relapse, consequences associated with HIV and use of multiple needles, and the potential lack of prenatal
care.
The Federal government mandates that prenatal care be available for pregnant women
on methadone. It is the responsibility of treatment providers to arrange this care. More
than ever, there is need for collaboration
involving obstetric, pediatric, and substance
abuse treatment caregivers. Comprehensive
care for the pregnant woman who is opioid
dependent must include a combination of
methadone maintenance, prenatal care, and
substance abuse treatment.
107
Pregnant women should be maintained on an

adequate (i.e., therapeutic) methadone dose.
An effective dose prevents the onset of withdrawal for 24 hours, reduces or eliminates
drug craving, and blocks the euphoric effects
of other narcotics. An effective dose usually is
in the range of 50150mg (Drozdick et al.
2002). Dosage must be individually determined, and some pregnant women may be
able to be successfully maintained on less
than 50mg while others may require much
higher doses than 150mg. The dose often
needs to be increased as a woman progresses
through gestation, due to increases in blood
volume and metabolic changes specific to
pregnancy (Drozdick et al. 2002; Finnegan
and Wapner 1988).
Generally, dosing of methadone is for a 24hour period. However, because of metabolic
changes during pregnancy it might not be possible to adequately manage a pregnant woman
during a 24-hour period on a single dose.
Split dosing, particularly during the third
trimester of pregnancy, may stabilize the
womans blood methadone levels and effectively treat withdrawal symptoms and craving.
Breastfeeding is not contraindicated for
women who are on methadone. Very little
methadone comes through breast milk; the
American Academy of Pediatrics (AAP)
Committee on Drugs lists methadone as a
maternal medication usually compatible with
breastfeeding (AAP 2001, pp. 780781).
Benzodiazepines
The principles of detoxification from benzodiazepines are the same for pregnant and nonpregnant patients. It is important to taper the
dose of benzodiazepine slowly in order not to
induce fetal withdrawal or other adverse consequences in the fetus or mother.
Detoxification is most likely safest during the
second trimester in order to avoid spontaneous abortion or premature labor. For more
information, see the forthcoming TIP
Substance Abuse Treatment: Addressing the
108
Specific Needs of Women (CSAT in development e). There is a documented withdrawal

syndrome in neonates who have been prenatally exposed to benzodiazepines (Sutton and
Hinderliter 1990), and this syndrome may be
delayed in onset more than that associated
with other drugs.
Stimulants
The principles of detoxification from stimulants
such as cocaine are the same for pregnant and
nonpregnant women. Since there is no current
pharmacotherapy to use in tapering individuals
from stimulant use, the use of any medications
to treat medical complications that might arise
from the withdrawal should only be done after
discussion with the patient of the risks and benefits of each medication.
Solvents
The principles of detoxification from solvents
are the same for pregnant and nonpregnant
women. It should be noted that based on a
review of case reports, there is a complex
array of characteristics that appear to be similar to fetal alcohol effects. Fetal Alcohol
Syndrome (FAS) is characterized by growth
deficiency (born small for gestational age;
failure to grow at a normal rate), particular
facial features (e.g., eyes are too close together, ears are set low on the head), and CNS
dysfunctions (mental retardation, microencephaly [small brain size]) and brain malformations (Costa et al. 2002). Thus fetal development in pregnant women who have a history of solvent abuse should be evaluated and
carefully monitored (Jones and Balster 1998).
Nicotine
There is extensive documentation that smoking
during pregnancy causes numerous adverse
fetal consequences (see Schaefer 2001).
Cigarette smoking during pregnancy is the
largest modifiable risk for pregnancy-related
morbidity and mortality in the United States
(Dempsey and Benowitz 2001). While women
Chapter 4
are undergoing detoxification, they should be

offered education about the risk of cigarette
smoking during pregnancy and, ideally, prevented from smoking. This is especially important since cigarette smoking is strongly associated with decreased birth weight, which is a predictor of developmental problems in newborns
(Ernst et al. 2002). If women are unable to stop
smoking using behavioral interventions, nicotine replacement products may be used; however, the woman should fully understand the
possible risks and benefits of these pharmacotherapies (Jones and Johnson 2001).
It also is important to point out to patients
that there are data to suggest that women may
derive less benefit from NRT than do men
and that they may derive greater benefit from
some non-NRT medications (e.g., bupropion),
thus producing quit rates in women comparable with those in men (Perkins 2001).
However, the data regarding the use of
bupropion during pregnancy are limited.
Examinations of the acute effects of NRT in
pregnant women reveal that nicotine has minimal impact on the maternal and fetal cardiovascular systems. NRT may well be viewed as
the lesser of two evils, inasmuch as smoking
cigarettes delivers, in addition to nicotine,
thousands of chemicals. Among these are
many that also are viewed as developmental
toxins (e.g., carbon monoxide and lead). It is
doubtful that the reproductive toxicity of
cigarette smoking is primarily related to nicotine. Thus, if NRT is to be used during pregnancy, the dose of nicotine in NRT should be
similar to the dose of nicotine that the pregnant woman received from her ad lib (whenever desired) smoking. Although intermittentuse formulations of NRT (e.g., chewing gum)
have been recommended over continuous-use
formulations (e.g., transdermal patch) due to
reductions in the total dose of nicotine delivered to the fetus (Dempsey and Benowitz
2001), it is unknown what the impact of intermittent acute doses followed by withdrawal of
nicotine has on the fetus.
Marijuana, anabolic steroids,

and club drugs
The principles of detoxification from these
drugs is the same for pregnant and nonpregnant women. The use of anabolic steroids during pregnancy is rare; however, these can be
catastrophic to a pregnancy, and if use is
found, a detailed ultrasound examination is
recommended to determine the morphological
(physical or structural) development of the
fetus (Scialli 2001).
Although the class of
While women are
club drugs is relatively new there have
undergoing
been a few reports
(McElhatton et al.
1999) suggesting that
detoxification,
there is an increased
risk of congenital
they should be
malformation in
neonates prenatally
offered education
exposed to ecstasy.
Other club drugs
about the risk of
such as flunitrazepam (Rohypnol)
cigarette smoking
may have effects similar to those of some
during pregnancy
benzodiazepines;
however, this is specand, ideally,
ulative. For comprehensive information
on the treatment of
prevented from
this specific population, see the forthsmoking.
coming TIP
Substance Abuse
Treatment:
Addressing the Specific Needs of Women
(CSAT in development e).
Older Adults
It has been recommended that, when treating
older adults, there should be a policy of using
age-specific group treatment that is both supportive and nonconfrontational (Royer et al.
2000; West and Graham 1999). Older adults
may be dealing with depression, loneliness,
109
and loss of career or a loved one. Thus, as a

standard policy, older adults should be
screened for depression and grief or lossrelated issues. Similar to the situation with
other specific populations, the detoxification
setting should ideally have in place a policy
that mandates, at a minimum, well-established linkage with general medical services
and specialized services for the aging, because
of their increased vulnerability to physical
ailments. Establishing policies that create an
environment that is positive and does not tolerate ageisma general tendency to react
negatively toward elderly adultsis important for the optimal treatment of older individuals.
Alcohol and other drug-related disorders in
elderly individuals often are more severe than
those of younger individuals and they are at
increased risk for co-occurring medical disorders. It is the medical complications rather
than age itself for which detoxification in a
medical setting is needed. The elderly may
have slower metabolism of medications making dosage adjustments necessary in some
cases. The elderly also may be at greater risk
for drug interactions, since they may be
receiving medications to treat other problems.
A complete and careful assessment with ongoing monitoring should be done to examine the
existence of diseases such as, but not limited
to, heart disease, respiratory disease, diabetes, and dementia. Potential for falls also
should be evaluated in the context of prescribed medications. The previously presented protocols for detoxification from alcohol,
opioids, benzodiazepines, stimulants, solvents, nicotine, marijuana, anabolic steroids,
and club drugs (anabolic steroids and club
drug abuse are rare in this population)
appear to be applicable to the elderly population as long as sensitivity to the withdrawal
medication is considered. TIP 26, Substance
Abuse Among Older Adults (CSAT 1998f),
provides comprehensive information on the
treatment of this population.
110
People With Disabilities or CoOccurring Conditions

In any patient population, the clinician
should expect to encounter persons with disabilities including co-occurring medical or
mental disorders. These patients often will
require special assistance to overcome both
physical and psychological barriers in undergoing detoxification and treatment, including
their own psychological barriers that must be
overcome, as well as those attitudinal and
communication barriers that often prevent
complete and clear understanding between
patient and clinician or clinician and institution. Effective communication is essential for
effective services. Accommodations must take
into consideration the expressed preference of
the individual with a disability. Substance
abuse treatment programs need to be in compliance with two Federal laws regarding this
matter: the 1992 Amendments to the
Rehabilitation Act of 1973 and the Americans
with Disabilities Act [ADA] of 1990.
According to the ADA, programs must
remove or compensate for physical or architectural barriers to existing facilities when
accommodation is readily achievable, meaning easily accomplishable and able to be carried out without much difficulty or expense
(P.L. 101-336 301). Providers should examine their programs and modify them to eliminate four fundamental groups of barriers to
treatment for people with disabilities and/or
co-occurring disorders: (1) attitudinal barriers; (2) discriminatory policies, practices, and
procedures; (3) communications barriers; and
(4) architectural barriers. Federal, State, and
other sources of assistance might be available
to fund ADA-related improvements. See TIP
29, Substance Use Disorder Treatment for
Disabilities (CSAT 1998g) for further information.
The following passage clarifies terms and
addresses the basic issues presented by
patients with disabilities and/or co-occurring
disorders. Diseases, disorders, and injuries,
Chapter 4
whether congenital or acquired, can have

diverse effects on organs and body systems.
Conditions (and diseases) such as multiple
sclerosis, traumatic brain injury, spinal cord
injury, diabetes, and cerebral palsy can lead
to impairments, such as impaired cognitive
ability, paralysis, blindness, or muscular dysfunction. These impairments in turn cause
disabilities, which limit an individuals ability
to function in various areas of life, such as
learning, reading, and mobility. While diseases, impairments, and disabilities are distinct categories, they often are used interchangeably. These essential terms are defined
in Figure 4-15.
The field of disability services has developed
its own terminology to discuss physical, sensory, and cognitive disabilities (see definitions
below), and many treatment providers of people with substance use disorders will not be
familiar with these terms as the profession
defines them. WHO has devised a method for
the classification of impairments and disabili-
ties (WHO 1980). This complex system has

been simplified here into four main categories:
1. Physical impairments are caused by congenital or acquired diseases and disorders
or by injury or trauma. For example,
spinal cord injury is a disorder that can
cause paralysis, an impairment.
2. Sensory impairments include blindness
and deafness, which may be caused by
congenital disorders, diseases such as
encephalopathy or meningitis, or trauma
to the sensory organs or the brain.
3. Cognitive impairments are disruptions of
thinking skills, such as inattention, memory problems, perceptual problems, disruptions in communication, spatial disorientation, problems with sequencing (the ability
to follow a set of steps in order to accomplish a task), misperception of time, and
perseveration (constant repetition of
meaningless or inappropriate words or
phrases).
Figure 4-15
Some Definitions Regarding Disabilities
Disease: An interruption, cessation, or disorder of body functions, systems, or organs.
Impairment: Any loss or abnormality of psychological, physiological, or anatomical structure or functions.
Disability: Any restriction or lack (resulting from an impairment) of the ability to perform an activity in
the manner or within the range considered normal for a human being. A disability is always perceived
in the context of certain societal expectations, and it is only within that context that the disadvantages
resulting from a disability can be properly evaluated.
Functional capacities: The degree of ability possessed by an individual to meet or perform the behaviors, tasks, and roles expected in a social environment.
Functional limitations: The inability to perform certain behaviors, fulfill certain tasks, or meet certain
social roles as a consequence of a disability. Those limitations can be anatomical (e.g., amputation),
physiological (e.g., diabetes), cognitive (e.g., traumatic brain injury), sensory (e.g., blindness, deafness), or affective (e.g., depression) in origin and nature. They represent substandard performance on
the part of the individual in meeting life activities and reflect the interaction between the person and the
environment. (A list of the areas of functional capacity and disabilities most often assessed is in Figure
4-16, p112.)
Sources: Livneh and Male 1993; Stedman 1990; World Health Organization (WHO) 1980.
111
Figure 4-16
Impairment and Disability Chart
Impairment Category
Common Disabilities
Physical
Spina bifida
Spinal cord injury
Amputation
Diabetes
Chronic fatigue syndrome
Carpal tunnel
Arthritis
Sensory
Blindness
Hearing impairment
Deafness
Deaf-blindness
Visual impairment
Cognitive
Learning disabilities
Traumatic brain injury
Mental retardation
Attention deficit disorder
Affective
Depression
Bipolar disorder
Schizophrenia
Eating disorder
Anxiety disorder
Posttraumatic stress disorder
Source: CSAT 1998e.

4. Affective impairments are disruptions in
the way emotions are processed and
expressed. For the purposes of this discussion, affective impairments are considered
to include problems caused by both affective and mood disorders, such as major
depression and mania. These impairments
include the symptoms of mental disorders,
such as disorganized speech and behavior,
markedly depressed mood, and anhedonia
(joylessness).
One of the most important practices that
should be in place as a standard in any detoxification setting is routine screening for dis-
112
abilities and co-occurring medical and/or psychiatric conditions. The failure to recognize
these problems in patients can result in poor
outcomes (Cook et al. 1992). Additionally,
intoxicated individuals with co-occurring
depressive disorders are at high risk for suicide attempts. Of course, an individual
patient may present with two or more disabilities and/or co-occurring disorders. Clinicians
treating people with co-occurring substance
use and mental disorders should consult TIP
42, Substance Abuse Treatment for Persons
With Co-Occurring Disorders (CSAT 2005b).
Chapter 4
All programs should make a good faith effort

to provide equal access in as comprehensive a
manner as possible for all patients. Individual
unique needs should be taken into account
when providing services. For example,
patients with physical, sensory, or cognitive
disabilities may need help with self-care (e.g.,
eating, grooming), moving (e.g., using stairs,
walking), communication (e.g., reading,
speaking), learning, social skills, and executive functions (e.g., planning and organization, decisionmaking). Unresponsiveness to
instructions, lack of participation in discussions and activities, forgetfulness, or confusion by an individual with cognitive disabilities should not be viewed as a lack of motivation, resistance, or denial. Programs may
need to develop the expertise or engage an
expert on cognitive disabilities to determine
the limitations resulting from the substance
abuse and those resulting from the disability.
Both require patience in the response.
Information presented to the person with a
cognitive disability should include different
and complementary media; for example, visual and tactile materials can reinforce the
usual verbal interaction.
al. Physical therapy and exercise, chiropractic care, biofeedback, hypnotism, and therapeutic heat or cold are some other approaches to caring for persons with physical problems. Most of these alternative treatments
have limited or no research support of their
efficacy; yet some clinicians believe they
work. Thus, consultation with experts on
their use is necessary before starting a person
with chronic pain on these remedies.
An alternative model supports the idea that
patients should be treated simultaneously in
substance abuse treatment, mental/physical
health, and detoxification settings, yet treatments may occur in separate facilities and be
conducted by separate staff. The consequent
task for all is to be supportive and knowledgeable about each others interventions.
The severity of the addiction and
medical/psychiatric problems at the time of
detoxification entry should determine which
acute services the patient receives first.
Naturally, a persons medical and psychiatric
disabilities must be accounted for in the
preparation of any treatment plan. In some
cases, substance abuse treatment cannot
begin until issues relating to medical and psychiatric disabilities are settled.
Programs also may need to alter their policies

regarding the use of drugs prescribed for pain
control, since most medications of this class
are drugs with a high abuse potential. A number of patients with substance use disorders
also live with chronic pain. Living in a drugfree state may not be desirable if it is associated with unrelieved pain, which can be quite
disabling. The clinician should explore with
patients what pain management options have
been tried in the past, and which management
medications are being used currently.
Patients should be encouraged to discuss
their feelings about pain and how it affects
their daily life, and especially to what extent
it curtails or prevents their participation in
the activities of daily living.
African Americans
There are a number of alternative treatments

for chronic pain. Acupuncture is already in
use in some treatment programs for detoxification to help relieve symptoms of withdraw-
For African Americans, entrance into detoxification has been associated with enrolling in further treatment, reductions in HIV/AIDS risk
behaviors, and linkages with social and health-
There are a number of resources for clinicians to employ, including experts in the field
of disability services. Figure 4-17 (p. 114) discusses ways of locating expert help for treating patients with disabilities and/or co-occurring disorders.
Finally, integrated treatment combines substance abuse treatment, treatment for cooccurring disorders, and detoxification services
into one program. For more complete information on the treatment of many of these disorders, see chapter 5.
113
Figure 4-17
Locating Expert Assistance
Experts in disability services can be located in several ways, depending upon the nature of the patients
disability and the local resources available. Patients who understand their disability may in fact be the best
experts on their condition and specific needs; however, it is not uncommon that persons requiring treatment for substance use disorders will not understand basic aspects of their situation or condition. In such
cases, immediate family members or close friends may be important sources of information and guidance.
The treatment team also should consider contacting other sources:
A disability-specific service organization (e.g., United Cerebral Palsy, organizations for the blind or deaf
such as the National Association of the Deaf and American Deafness and Rehabilitation Association, the
Association for Retarded Citizens)
Social workers
Case managers
Rehabilitation specialists
Psychologists
Nurses or physicians associated with a social service agency providing disability services for the individual
patient in question (e.g., vocational rehabilitation, family services for people who are deaf and hard of
hearing, the Department of Veterans Affairs physical rehabilitation unit, community case management
services)
Other organizations recognized by the disability community (e.g., Centers for Independent Living, governors committees for persons with disabilities, Paralyzed Veterans of America, local or State consumer
coalitions for persons with disabilities)
Source: CSAT 1998e.

care services (Lundgren et al. 1999). African
Americans are at greater risk than other populations for the co-occurrence of diabetes and
hypertension (high blood pressure) that can
predispose them to a risk of stroke. This
should be taken into account when placing and
monitoring them on withdrawal medications.
In treating African-American patients, treatment efficacy and therapist efficacy may be
associated with the therapists understanding
of how race plays a role in recovery
(Luborsky et al. 1988; Pena et al. 2000). In
addition, when working with counselors from
other cultures, African Americans may display mistrust and a reluctance to show any
weakness. To overcome this mistrust and to
build rapport, especially when the clinician is
discussing the detoxification process, it is particularly important for the clinician to keep in
114
mind the standard of respecting the client as

an equal partner in treatment. For further
information on this subject (as well as information on working with members of other
cultural/ethnic groups), see the forthcoming
TIP Improving Cultural Competence in
Substance Abuse Treatment (CSAT in development a).
The previously discussed protocols for detoxification from all substance of abuse appear
adequate for the detoxification of African
Americans. However, there are a few further
aspects to consider:
If treating African Americans with beta
blockers, propranolol is less effective in
treating African Americans than Caucasians
(Pi and Gray 1999).
African Americans are more likely (15 to 25
percent) to have less of the enzyme activity
Chapter 4
needed to eliminate diazepam than others, so

it may have a longer half-life in African
Americans than it does in other ethnic groups
(Pi and Gray 1999).
Since co-occurring disorders such as depression frequently are seen in people with substance use disorders, it is important to know
that African Americans may require lower
doses and may be at greater risk of developing toxic side effects when prescribed antidepressants, since they are likely to metabolize
tricyclic antidepressants and SSRIs less efficiently than Caucasians (Pi and Gray 1999).
Although the clearance of nicotine is similar
for African Americans and Caucasians, the
clearance of cotinine, a metabolite of nicotine, is slower in African Americans, which
may cause different smoking patterns than
found in Caucasians (Ahijevych 1998).
Asians and Pacific Islanders

This group is the most diverse in nations of
origin and has widely differing languages,
beliefs, practices, dress, and values. Often
the only common thread among these people
is their geographic origin (Chang 2000).
Although this group appears to have lower
rates of alcohol and illicit drug use, these
problems should not be overlooked; members
of this group may not seek treatment until the
problems are quite severe. Successful treatment involves the family and important values include balance, harmony, wisdom, and
modesty. Thus, it may be important to talk to
the family about the process of detoxification
and dispel their fears and concerns as well as
the patients.
Asians and Pacific Islanders tend to be concerned about the clinicians credibility and
trustworthiness. Generally speaking, maleness, mature age, the projection of self-confidence, possession of sound cultural competence skills, good educational background,
and level of experience are of importance. In
addition, a concrete logical approach to the
problem at hand is valued (Brems 1998). The
previously discussed protocols for detoxification from all substances of abuse appear ade-
quate for the detoxification of Asians and

Pacific Islanders. During the detoxification
process, there are a number of issues to consider:
If possible and appropriate, incorporate traditional healing methods (e.g., meditation
and religious exercises). These can help
reduce stress and anxiety and promote recovery (Chang 2000). While there is a large
immigrant population among many AsianAmerican groups, it is erroneous to assume
that all are foreign born. Variation in practice of traditional healing methods is considerable and consistent with generational differences. When considering detoxification,
recognize the importance of bicultural practices, values, and beliefs that might influence
responsiveness to treatment.
When discussing detoxification medications,
discuss with patients their feelings about taking Western medications for detoxification.
In some Southeast Asian cultures, Western
medications are believed to be too strong for
the Asian person. It is important to assess a
persons feelings about these since the patient
may not wish to disagree with the clinician
yet may be noncompliant in taking the medications. Compliance with detoxification medication may be better achieved if doses are
reduced or regimens shortened, yet this
should only be attempted if it is in the best
interest of the patient.
Racial differences in alcohol sensitivity
among Asians and Caucasians have long been
recognized, with more than 80 percent of
some Asians compared to 10 percent of
Caucasians being sensitive to alcohol (i.e.,
having a flushing reaction) (Wolff 1972,
1973). This is the result of genetic differences
in alcohol metabolizing enzymes.
Approximately 50 percent of Asians lack the
enzyme ALDH2, found in the liver, that helps
the body get rid of alcohol (Hsu et al. 1985;
Yoshida et al. 1985). One reason for lower
drinking rates among Asians may be the
flushing reaction in the face and body following alcohol ingestion and an increase in skin
temperature. Other uncomfortable signs and
symptoms associated with the negative reac-
115
tion to alcohol ingestion can include nausea,

dizziness, headache, fast heartbeat, and anxiety (Caetano et al. 1998).
Five studies have shown that the metabolism
of codeine is slower in Chinese people than
in Caucasians. Chinese patients seem to
require lower doses of codeine, since the
slower metabolism leads to a higher concentration of codeine in the blood (Smith and
Lin 1996).
If treated with beta blockers, Asians require
much lower doses than Caucasians, since
they are very sensitive to this medications
blood pressure and heart rate effects (Pi
and Gray 1999).
Asians as a group have a higher number of
individuals than other ethnic groups who
are poor metabolizers of diazepam. This
may result in the need for lower doses,
since they report greater sedative effects
with a typical dose (Lesser et al. 1997). It
also may be that a lower body fat, which is
typical of Asian-American individuals, can
lead to differences in the pharmacokinetics
of lipophilic drugs (Lesser et al. 1997).
In treatment for co-occurring depression
and a substance use disorder, Asians
appear to metabolize clomipramine more
slowly than Caucasians (Pi and Gray 1999).
In contrast, Asians may metabolize
phenelzine faster, resulting in the need for a
higher dose relative to that which would be
appropriate for Caucasians (Pi and Gray
1999).
Chinese Americans tend to metabolize nicotine 35 percent more slowly than
Hispanics/Latinos and Caucasians. Thus,
they may need to smoke less frequently and
take in less nicotine to achieve the same
nicotine levels as do Hispanics/Latinos and
Caucasians. This may have implications for
the dosing of NRTs (Benowitz et al. 2002).
Smoking rates among male Asian
Americans, especially immigrant males, are
exceedingly high and masked by the lower
rates among Asian-American females.
116
American Indians
There are currently more than 500 federally
recognized American-Indian tribes, and there
is among them great variability in appearance, dress, values, religious beliefs, practices, and traditions. More than 200 different
languages are spoken by American-Indian
tribes. Alcohol use varies widely among tribes
(Mancall 1995). Of all ethnic and racial
groups, American Indians have the greatest
rates of alcohol and illicit drug use (Office of
Applied Studies 2002a).
An early study of treatment utilization by
American Indians found that there was a significant association between involvement in
society and treatment outcomes. Those
involved in either the traditional Indian society or both the traditional Indian society and
Caucasian society had more than a 70 percent
success rate, whereas those involved in neither society had a 23 percent success rate
(Ferguson 1976). At a 10-year followup, those
who had reported greater Indian culture affiliation and more severe liver dysfunction at
baseline had better alcohol treatment outcomes (Westermeyer and Neider 1984).
When engaging an American Indian in the
process of detoxification, moving through the
process too quickly or abruptly can be perceived as showing a lack of caring and is considered contrary to trust building (Brems
1998). The pace of conversation is important;
a slower pace is more agreeable than a rapid
conversation. Moreover, a confrontational
approach also is not advised with this population (Abbott 1998). American Indians may
want a close and involved relationship with
their therapists and often want the clinician
to be a friend or relative (Brems 1998). The
trust often is built by idle small talk to a level
of shared understanding. Use of fables and
illustrative stories to express ideas can be
extremely helpful. According to the forthcoming TIP Improving Cultural Competence in
Substance Abuse Treatment (CSAT in development a), avoidance of eye contact also is
traditional. The Talking Circle is a native tra-
Chapter 4
dition that can be helpful in the treatment

process (Canino et al. 1987; Coyhis 2000).
The previously discussed protocols for detoxification from all substances of abuse appear
adequate for the detoxification of American
Indians. The following are some issues to consider during detoxification.
Fetal Alcohol Syndrome is 33 times higher in
this population than the national average
(CSAT in development a). This may be
important for pregnant women coming to
detoxification and also may be important if
the adult has FAS.
Indian women who drink have a six-fold
increase in cirrhosis of the liver relative to
Caucasian women (Heath 1989).
Although some American Indians have
reported a flushing response to alcohol, it
appears that the flushing reaction in
American Indians is milder and less adverse
than that experienced by Asians (Gill et al.
1999).
If Alcoholics Anonymous or other 12-Step
programs are to be introduced, framing the
steps in terms of a circle rather than a ladder
may be better received, since the circle is
important concept in Indian culture (CSAT
in development a).
If possible and appropriate, other traditional
methods that can help recovery are sweat
lodges, vision quests, smudging ceremonies,
sacred dances, and four circles (Abbott
1998).
Overall, detoxification for this population is
the same as for other populations, but
American Indians are likely to seek treatment
later and have more medical complications
and poorer nutrition (Abbott 1998).
Hispanics/Latinos
Hispanics/Latinos are now the largest ethnic
minority group in America. Assessment of the
patients level of acculturation can be helpful
in understanding substance abuse patterns.
Language is one of the most difficult barriers
to treatment entry and success for
Hispanics/Latinos. However, simply knowing
Spanish or Portuguese does not guarantee

cultural sensitivity or competence. For
instance, it is important that the treatment
staff understand the role of the family. The
functional family can be extended and should
take into account people who have day-to-day
contact with and a role in the family
(Markarian and Franklin 1998).
Hispanics/Latinos are likely to view drug
dependency as moral failing or personal
weakness. Traditional healing such as folk
remedies and folk
healers may provide
benefit. The previHispanics/Latinos
ously discussed protocols for detoxificaare now the
tion from alcohol,
opioids, benzodilargest ethnic
azepines, stimulants,
solvents, nicotine,
minority group in
marijuana, anabolic
steroids, and club
America.
drugs appear adequate for the detoxiAssessment of the
fication of
Hispanics/Latinos.
patients level of
Gays and
Lesbians
acculturation can
be helpful in
Approximately 5 to
33 percent of all lesunderstanding
bian and gay individuals are estimated to
substance abuse
have a substance
abuse problem
patterns.
(Cochran and Mays
2000; Hughes and
Wilsnack 1997). A
contributing factor may be the stress and
anxiety associated with the social stigma
attached to homosexuality. Further, alcohol
and drugs may serve as an escape and ease
social interactions at social settings such as
bars. More information on this subject will be
available in the forthcoming TIP Improving
Cultural Competence in Substance Abuse
Treatment (CSAT in development a). The
previously discussed protocols for detoxifica-
117
tion appear adequate for gay and lesbian

patients. Since numerous misconceptions and
stereotypes exist concerning gay and lesbian
individuals, it is important for the clinician to
assess his beliefs and take care not to impose
them on the patient.
There are a number of principles of care for
treating gay and lesbian individuals, which
are outlined in A Providers Introduction to
Substance Abuse Treatment for Lesbian,
Gay, Bisexual, and Transgender Individuals
(CSAT 2001). These principles include: (1)
counselors being able to monitor their own
feelings about working with this population of
patients in order to provide professional, ethical, and competent care; (2) helping patients
heal from the negative experiences of homophobia and heterosexism; (3) helping patients
understand their reactions to discrimination
and prejudice; and (4) helping patients accept
personal power over their own lives by helping them improve their self-images and build
support networks.
Adolescents
The previously discussed protocols for detoxification from all substances of abuse appear adequate for the detoxification of adolescents;
however, there are several additional aspects to
consider:
Physical dependence generally is not as
severe, and response to detoxification is more
rapid than in adults.
Retention is a major problem in adolescent
treatment (Thurman et al. 1995).
Peer relationships play a large role in treatment. Among adolescents who do not use
drugs, few of their friends reported use. In
one study, among those who reported specific
drug use, over 90 percent of their friends
reported using the same drug (Dinges and
Oetting 1993).
It is estimated that 75 percent of those
reporting steroid use are high school students, and most of them are male. Detoxification from steroids does not typically require
specific pharmacological intervention unless
118
there is liver toxicity or suicidal intent

(Giannini et al. 1991). The use of club drugs
is higher in this population than in others.
TIP 31, Screening and Assessing Adolescents
for Substance Use Disorders (CSAT 1999d),
and TIP 32, Treatment of Adolescents With
Substance Use Disorders (CSAT 1999f), provide comprehensive information on the treatment of adolescents.
Incarcerated/Detained Persons
Substance use disorders are common among
inmate populations. At the time of arrest and
detention, it has been estimated that 70 to 80
percent of all inmates in local jails and State
and Federal prisons had regular drug use or
had committed a drug offense, and 34 to 52
percent of these inmates were intoxicated at
the time of their arresting offense (Federal
Bureau of Prisons 2000; Mumola 1999).
Although women comprise a small proportion
of the incarcerated population (12.3 percent
in jails and 7.4 percent in State and Federal
prisons) than men (Harrison et al. 2004),
females have a greater prevalence of illicit
drug use (i.e., 40 percent compared to 32 percent were under the influence of drugs at the
time the crime was committed) than do males
(Greenfeld and Snell 1999).
Persons who are incarcerated or detained in
holding cells or other locked areas should be
screened for physical dependence on alcohol,
opioids, and benzodiazepines and provided
with needed detoxification and treatment.
Screening should occur over time, since the
onset and intensity of withdrawal is dependent on the type of drug taken, when the person last took the drug, and how long the drug
lasts in the persons body. The duration of
detention will affect what detoxification services can be provided, and many facilities will
not be able to provide detoxification or continuing care services. There are some special
considerations for the detoxification of this
population:
Abrupt withdrawal from alcohol can be lifethreatening.
Chapter 4
Abrupt withdrawal from opioids or benzodiazepines is not life-threatening but can

cause severe withdrawal signs and symptoms and great distress.
Many correctional facilities have restrictions on the use of methadone or LAAM and
special provisions for maintaining or tapering the individual may need to be made.
It should be determined whether dependence on either opioids or benzodiazepines

is the result of illicit use and not the result
of taking medications that have been prescribed to treat pain or anxiety disorders.
If medications are provided to medically

detoxify inmates, the Federal Bureau of
Prisons Clinical Practice Guidelines for
Detoxification of Chemically Dependent
Inmates (2000) suggest retaining strict control over access to these medications to prevent diversion or misuse (e.g., eating clonidine patches to obtain a state of euphoria).
If medically supervised withdrawal is indicated, the substitution of a long-acting drug

from the same class of substances the
patient is using (e.g., giving methadone to
treat heroin dependence) and the gradual
tapering of that substance (no faster than
10 to 20 percent per day) should be conducted under closely monitored settings.
There are cases when individuals maintained on opioid agonist medications are
detained or incarcerated. If the incarceration is 30 days or less, the individual should
be maintained on her usual dosage. If the
incarceration is longer, the individual may
be appropriate for gradual dose tapering.
TIP 44, Substance Abuse Treatment for

Adults in the Criminal Justice System (CSAT
2005b), and TIP 30, Continuity of Offender
Treatment for Substance Use Disorders From
Institution to Community (CSAT 1998b), provide more detailed information about the
treatment of this population. TIP 21,
Combining Alcohol and Other Drug Abuse
Treatment With Diversion for Juveniles in
the Justice System (CSAT 1995b), also provides information about incarcerated youth.
Persons who transition from a state of opioid dependence to a drug- or medicationfree state are at greater risk of overdose
upon relapse to opioid use.
119
5 Co-Occurring Medical
and Psychiatric
Conditions
In This
Chapter
General Principles
of Care for
Patients With CoOccurring Medical
Conditions
Treatment of
Co-Occurring
Psychiatric
Conditions
Standard of Care
for Co-Occurring
Psychiatric
Conditions
Patients undergoing detoxification frequently present with medical

and psychological conditions that can greatly affect their overall wellbeing and the process of detoxification. These may simply be preexisting medical conditions not related to substance use or the direct
outcome of the substance abuse. In either case, the detoxification process can negatively affect the co-occurring disorder or vice versa.
Furthermore, people who abuse substances often present with medical
conditions in advanced stages or in a medical crisis. Co-occurring
mental disorders also are likely to be exacerbated by substance abuse.
For more on treating patients with co-occurring psychiatric disorders,
the reader should refer to TIP 42, Substance Abuse Treatment for
Persons With Co-Occurring Disorders (Center for Substance Abuse
Treatment [CSAT] 2005c).
This chapter is intended primarily for medical personnel treating
patients in detoxification settings, though nonmedical staff may find it
informative as well. This chapter is not meant to take the place of
authoritative sources from internal medicine. Rather, it presents a
cursory overview of special conditions, modifications in protocols, and
the use of detoxification medications in patients with co-occurring
conditions or disorders. Overall treatment of specific conditions is not
addressed unless modification of such treatment is needed.
121
General Principles of
Care for Patients With
Co-Occurring Medical
Conditions
Patients who use substances can present with
any of the conditions or combinations of conditions that can be found in the general population. In most cases, the management of the
medical condition in the patient with a substance use disorder diagnosis does not differ
from that of any other patient. However, the
medication used for detoxification and the
actual detoxification protocol may need to be
modified to minimize potentially harmful
effects relevant to the co-occurring condition.
Detoxification staff providing support should
be familiar with the signs and symptoms of
common co-occurring medical disorders.
Likewise, personnel at medical facilities (i.e.,
emergency rooms, physicians offices) should
be aware of the signs of withdrawal and how
it affects the treatment of the presenting medical conditions.
The setting in which detoxification is carried
out should be appropriate for the medical
conditions present and should be adequate to
provide the degree of monitoring needed to
ensure safety (e.g., oximetry [a measurement
of the amount of oxygen present in the
blood], greater frequency of taking vital
signs, etc.). Acute, life-threatening conditions
need to be addressed concurrently with the
withdrawal process and intensive care unit
monitoring may be indicated.
Clinicians should keep in mind that consultation with specialists in infectious diseases,
cardiology, pulmonary medicine, hematology,
neurology, and surgery may be warranted.
Whenever possible, consent should be sought
to involve the patients primary healthcare
provider in the coordination of care.
Attending medical staff should be aware that
co-occurring medical conditions present an
opportunity to engage patients. By focusing
on the adverse effects of the substance abuse
122
on the overall health of patients, staff members are in a position to help patients see the
importance of engaging in treatment for their
substance use disorders. Patients should have
appointments for followup care made prior to
detoxification discharge for all chronic medical conditions, conditions needing further
evaluation, and substance abuse treatment.
This section highlights the conditions most
frequently seen in individuals who abuse substances, though it is not inclusive. Disorders
of the following systems will be covered: gastrointestinal (including the gastrointestinal
[GI] tract, liver, and pancreas), cardiovascular system, hematologic (blood) abnormalities, pulmonary (lung) diseases, diseases of
the central and peripheral nervous system,
infectious diseases, and special miscellaneous
disorders. Where special considerations are
needed for a patient presenting with a given
disorder in a detoxification setting they are
listed following the heading Special
Considerations.
Gastrointestinal Disorders
Frequently, the use of substances can present
a range of gastrointestinal problems. Cocaine
use, for example, can result in various gastrointestinal complications, including gastric
ulcerations, retroperitoneal fibrosis, visceral
infarction, intestinal ischemia, and gastrointestinal tract perforations (Linder et al.
2000). Gastrointestinal disorders may affect
many different organs and organ systems
(e.g., liver, pancreas), making diagnosis difficult. Since symptoms can be vague and
patients are not always able to articulate the
specific problem, diagnosis can be difficult.
For a simple rule of thumb, urgent attention
is needed if the patient is diagnosed with any
of the following:
Appendicitis
Abdominal aortic aneurysm
Perforated peptic ulcer
Boerhaaves Syndrome (spontaneous
esophageal rupture)
Obstructed or strangulated bowel
Chapter 5
Ischemic bowel disease (a condition that

results from inadequate blood supply to the
intestines)
may decrease lower esophageal sphincter pressure and aggravate reflux (DellItalia 1994).
Abcess of the pancreas or liver
MalloryWeiss Syndrome
Ruptured spleen or other trauma to the

abdominal area
Other possible diagnoses of abdominal pain
include:
Hepatitis
Peptic ulcer (nonperforating)
Peritonitis
Acute pancreatitis
Pelvic inflammatory disease
Endometriosis
Nephrolithiasis (kidney stones)
Inflammatory bowel disease
Ovarian cysts
Clinicians should also be aware of some deceptive causes of abdominal pain:
Myocardial infarction
Pulmonary emboli
Herpes zoster (shingles)
Acute pylonephritis (kidney infection)
Specific co-occurring gastrointestinal disorders
requiring special attention in patients undergoing detoxification are discussed below.
Reflux esophagitis
Reflux esophagitis can be a result of alcohols
effect on the lower esophageal sphincter (i.e.,
relaxation) and a decrease in peristalsis of the
distal esophagus, allowing gastric contents to
come into contact with the lower esophagus.
Typical symptoms include burning in the epigastric or retrosternal area (commonly called
heartburn or indigestion). Esophageal
bleeding can result from reflux esophagitis and
esophageal varices (resulting from portal
hypertension).
Special considerations
Several drugs used in typical protocols, such as
beta blockers and calcium channel blockers,
Co-Occurring Medical and Psychiatric Conditions
MalloryWeiss Syndrome is caused by torn

mucosa of the esophagus at the gastroesophageal junction due to protracted or violent vomiting. MalloryWeiss Syndrome is the
etiology of 5 to 15 percent of all upper GI
bleeds (Schuylze-Delrieu and Summers 1994).
Boerhaaves
syndrome
Boerhaaves syndrome is manifested
Co-occurring
by rupture of the
esophagus. Patients
medical conditions
presenting with this
condition complain of
present an
acute epigastric pain
(83 percent of
opportunity to
patients), vomiting
(79 percent), and
shortness of breath
engage patients in
(39 percent) as the
predominant, nonspetreatment for
cific symptoms. This
lack of specificity can
their substance
delay making the correct diagnosis (Brauer
use disorders.
et al. 1997).
Tachycardia,
cyanosis, and subcutaneous emphysema
also can be seen. If
this condition is left
untreated, the prognosis is severe.
Gastritis
Gastritis is described as the disruption of the
gastric mucus lining that allows gastric acid to
contact the mucosa with resultant inflammation
and possible bleeding. The patient presents
with nausea, vomiting, and abdominal pain
(Ivey 1981). Alcohol increases gastric acid
secretion and reduces the mucosal cell barrier,
123
allowing back-diffusion of the gastric acid into

the mucosa. This frequently causes an occurrence of erosive gastritis in the individual with
an alcohol use disorder (Fenster 1982).
Aspirin and nonsteroidal medications should be
avoided in the withdrawal protocols.
Pancreatitis
Pancreatitis can be
caused by many factors, although studDetoxification
ies suggest that alcohol may be a factor
staff providing
in anywhere from 5
to 90 percent of all
support should be
cases (Apte et al.
1997), with some
familiar with the
experts suggesting
about 60 percent of
signs and
all cases result from
excessive alcohol
symptoms of comconsumption
(Yakshe 2004). The
acute condition premon co-occurring
sents with abdominal pain, which is
medical conditions.
described as sharp,
burning, and constant and is located
in the epigastric
area of the
abdomen with radiation to the back.
Presenting symptoms and signs can include
abdominal tenderness, decreased bowel
sounds, low-grade fever, tachycardia, nausea,
and vomiting. Pancreatitis can proceed to a
chronic condition where pancreatic calcification, diabetes mellitus, malabsorption, and
chronic abdominal pain occur.
There may be a need to forbid oral intake of
food and medications, necessitating a change
of route of administration of both food and
medications to intravenous forms. In alcohol
withdrawal protocols, Ativan might be consid-
124
ered as an appropriate agent, as it can be

administered intravenously or intramuscularly. Opioids may have to be used to control
pain.
Liver disorders
Liver disease can range from fairly benign
fatty liver, which presents usually as an
asymptomatic enlargement of the liver associated with mild elevation of the serum liver
enzymes, to a broad spectrum of viral infections and the toxic consequences of alcohol
and other drug use. The end point of liver
disease is liver necrosis or failure. Midway in
the progression of liver disease is acute alcoholic hepatitis. The presentation is one of
liver tenderness, jaundice, fever, ascites, and
an enlarged liver. The patient is quite sick
and frequently has nausea and vomiting.
Alcoholic hepatitis usually needs acute medical treatment to prevent electrolyte imbalance
and dehydration. Protocols may have to be
adapted if the patient cannot take oral
agents.
Portal hypertension
Portal hypertension is a frequent consequence of liver disease. If elevation of the
portal pressure goes untreated, esophageal
varices develop and hemorrhage can ensue.
Treatment of acute hemorrhage includes
endoscopic sclerotherapy or ligation. Initial
therapy should include prompt and adequate
intravascular volume replacement, correction
of severe anemia and coagulopathies, and
adequate airway management.
Propranolol or isosorbide therapy is effective
in the prophylaxis of variceal bleeding
(Trevillyan and Carroll 1997), though beta
blockers can interfere with measuring the
true heart rate that determines the content of
many detoxification protocols. If bleeding is
Chapter 5
present, changeover to intravenous medication protocols is recommended, as the patient

will not be able to take oral medications.
Cirrhosis
Cirrhosis, or the formation of fibrous tissue
in the liver, leads to a state of increased resistance in the hepatic venous circulation. The
inability of blood to flow freely gives rise to
portal hypertension with ensuing esophageal
varices, splenomegaly, ascites, dilatation of
superficial veins, peripheral edema, and hemorrhoids.
Liver necrosis can be seen in patients who use
inhalants, particularly chronic use of benzene
and carbon tetrachloride. African Americans
and Hispanics/Latinos have higher mortality
rates from cirrhosis of the liver resulting from
alcohol abuse than do Caucasians and Asians
and Pacific Islanders (Sutocky et al. 1993).
Liver function test abnormality and jaundice
can occur in individuals who use anabolic
steroids, but this usually resolves on cessation
of the drugs. Studies in the elderly show that
1-year mortality was 50 percent among
patients over age 60 with cirrhosis, versus 7
percent for those under age 60 (Potter and
James 1987). Great care needs to be used
when giving diuretics to elderly patients with
cirrhosis, since their total body water may
already be decreased, making them more susceptible to fluid and electrolyte depletion
(Scott 1989).
Alcohol-related hepatic injury is seen in a
higher proportion of women due to a possible
potentiation (strengthening) of this effect by
estrogen (Brady and Randall 1999).
For the treatment of alcohol withdrawal,
lorazepam (Ativan) is well tolerated in
patients with severe liver disease (DOnofrio
et al. 1999) as is oxazepam (Serax), with its
short half-life of 6 to 8 hours and simple
metabolism with no metabolites.
Cardiovascular Disorders
The presentation of chest pain or discomfort
remains one of the most difficult differential
diagnoses to sort through, as disorders of several systems can cause this single complaint.
Inability to correctly diagnose this symptom
can be brought about by the patients inability to be interviewed and give succinct symptoms (the intoxicated or severely withdrawing
patient), a sociocultural or educational level
that does not allow for the verbal nuances
necessary to making a diagnosis, or fabrication of symptoms by a patient seeking to
obtain pain medications or other drugs.
A normal resting electrocardiogram does not
rule out the presence of organic heart disease
and the presence of nonspecific changes does
not necessarily mean that heart disease is present. Final diagnoses can range from reflux to
myocardial infarction brought about by
underlying ischemic heart disease or the use
of cocaine. Frequently, lung diseases can have
as their presenting symptom chest discomfort.
The consensus panel believes that this condition should never be overlooked or minimized
and it is imperative that an especially prompt
diagnosis be made and treatment be undertaken to ensure patient safety.
Underlying cardiac illness could be worsened
by the presence of autonomic arousal (elevated blood pressure, increased pulse and sweating) as seen in alcohol, sedative, and opioid
withdrawal. Thus prompt attention to these
findings and aggressive withdrawal treatment
is indicated. Special considerations for the
treatment of specific cardiac conditions are
outlined below.
Hypertension
Hypertension frequently is seen in the detoxification patient. Evaluation should include a
complete history to determine if the elevated
blood pressure predated the present withdrawal status. Consideration should be given
to include serum electrolytes, urinalysis,
BUN/creatinine, and an EKG in the detoxifi-
125
cation units initial workup. More elaborate

workup can be carried out after completion
of detoxification.
Propranolol (Inderal), labetalol (Trandate)
and metoprolol (Lopressor) are the beta
blockers of choice for treating hypertension
during pregnancy (McElhatton 2001), however, the impact of using them for alcohol
detoxification during pregnancy is unclear. If
treating African Americans with beta blockers, clinicians should be aware that propranolol is less effective in this population than it
is in Caucasians (Pi and Gray 1999). Asians
require much lower doses of beta blockers
than Caucasians, inasmuch as they tend to be
very sensitive to the blood pressure and heart
rate effects (Pi and Gray 1999).
The presence of a hypertensive history and
poorly controlled blood pressures may have
an effect on the proper evaluation of withdrawal as the examiner would have difficulty
determining whether the elevated blood pressure was due to withdrawal or to the underlying hypertensive history. Thus modifications
of the usual parameters and scheduling of
detoxification medications should be considered. In any event, severe elevation of blood
pressure should be treated concurrently with,
at minimum, salt restriction and rest. If the
blood pressure is still elevated in several days
despite a reduction in other withdrawal
parameters and symptoms, then medication is
warranted.
Beta blockers and clonidine have been used
in the treatment of alcohol withdrawal and
clonidine also has been used in opioid protocols. These medications can help control
blood pressure and also work well in the protocol. Calcium channel antagonists have also
been used to ameliorate some of the symptoms
of alcohol withdrawal and can be used concurrently for blood pressure control.
126
Ischemic heart disease

Ischemic heart disease presents as chest pain
or pressure, palpitations, dizziness, and/or
shortness of breath and requires immediate
attention, which will dictate what setting is
appropriate for the detoxification.
Cocaine use is associated with various cardiovascular complications including angina pectoris, myocardial infarction, and sudden
death. It is estimated that over half of the
64,000 patients evaluated annually for
cocaine-associated chest pain will be admitted
to hospitals for evaluation of myocardial
ischemia. Only about 6 percent of patients
will demonstrate biochemical evidence of
myocardial infarction (Hoffman and
Hollander 1997). The typical patient with
cocaine-related myocardial infarction is a
male in his mid-30s with a history of chronic
tobacco and repetitive cocaine use (Hollander
1995). This effect of cocaine appears to be
increased because the drug causes an increase
in myocardial oxygen demand and thus a
decrease in oxygen supply. These two factors,
which are caused by vasospasm and vasoconstriction of the coronary arteries, may lead to
cardiovascular disorders.
Patients with recent cocaine use can experience persistent cardiac complications such as
prolonged QT interval and vulnerability for
arrhythmia and myocardial infarction
(Chakko and Myerburg 1995). (QT is the Q to
T interval measured on EKGs. If the interval
is prolonged, it can lead to cardiac rhythm
disturbances.) Amphetamines are rarely
reported as the cause of myocardial infarction, though a case report shows that a
patient subsequently experienced a nonQwave anterior wall infarction associated with
amphetamine use (Waksman et al. 2001).
Cocaine use and HIV infection have been
associated with an increased incidence of cardiac dysfunction, but concomitant exposure
may cause a synergistic effect (Soodini and
Morgan 2001).
Chapter 5
Arrhythmias
Beta-adrenergic blocking agents may exacerbate cocaine-induced coronary arterial vasoconstriction and thereby increase the myocardial ischemia. Nitroglycerin and verapamil
reverse cocaine-induced hypertension and
coronary arterial vasoconstriction and are
the medications of choice in the patient who
uses cocaine and presents with chest pain
(Pitts et al. 1999). Cocaine may cause platelet
activation leading to acute coronary events
thus more aggressive antiplatelet therapy may
be indicated (Callahan et al. 2001).
Arrhythmias (irregular heartbeats) can be

seen in the presence of ischemia and cardiomyopathy. Two specific cases of arrhythmogenic disorders are holiday heart, where
the patient who has ingested alcohol presents
with supraventricular arrhythmia
(Greenspon and Schaal 1983), and the individual who uses cocaine with the stimulant
leading to significant atrial and ventricular
arrhythmias. Consumption of anabolic
steroids also has
been associated with
hypertension,
Cocaine use is
ischemic heart disease, cardiomyopaassociated with
thy, and arrhythmia
(Sullivan et al.
various
1999).
Cardiomyopathy
Cardiomyopathy is caused by degenerative
changes of the cardiac muscle with enlargement of the heart (cardiomegaly) and left ventricular failure. Alcoholic cardiomyopathy
presents with a similar picture as cardiac failure from other etiologies, with shortness of
breath on exertion, shortness of breath when
the patient is lying flat, and edema of the
lower extremities.
Besides alcohol as the etiology, a dilated cardiomyopathy can be seen with use of the
inhalant trichlorethylene. Cardiomyopathy in
the elderly patient with an already underlying
ischemic or atherosclerotic heart disease can
be quite debilitating. Women have shown
alcohol metabolism different from that of men
and distinct pathophysiologic mechanisms,
which frequently lead to a higher sensitivity
to alcohol-induced heart damage. The prevalence of cardiomyopathy in women is equal to
that in men, despite cases in which women
have consumed far less ethanol (FernandezSola and Nicolas-Arfelis 2002).
Alcoholic cardiomyopathy may respond poorly to digitalis with increased likelihood of digitalis toxicity (Zakhari 1991).
cardiovascular
Treatment of arrhythmia in the person who

abuses substances is
similar to that for the
patient who does not
abuse substances,
though the setting of
detoxification may
have to be altered to
allow for cardiac
monitoring (telemetry).
complications
including angina
pectoris,
myocardial
infarction, and
sudden death.
Hematologic
Disorders
Hematologic (blood) disorders can be seen due
to several factors, such as a direct toxic effect
of the drug on the bone marrow, as seen in
alcohol and benzene use, or as a result of malabsorption of essential nutrients (B12, folate),
or as a general poor state of nutrition.
127
Anemia
Anemia can be seen due to folate deficiency,
iron deficiency, B12 deficiency, acute blood
loss, or more frequently as a combination of
factors. Folate deficiency can cause a megaloblastic anemia, which is diagnosed by
macroovalocytes and hypersegmented neutrophils seen on a peripheral blood smear.
Iron deficiency anemia results from blood loss
and thus subsequent iron loss. This can be
seen in low-level
gastrointestinal
bleeding, after
childbirth, and as a
result of menstrual
Traumatic brain
blood loss. The presentation of anemia
usually is nondeinjury (TBI)
script with generalized fatigue and
should always be
weakness. With
severe anemia,
considered in
shortness of breath
on exertion and an
patients with
elevated heart rate
can be seen.
neurological
Specific to the
megaloblastic aneimpairment.
mias (B12 and
folate deficiency)
one can see neurologic complications
such as peripheral
neuropathy.
White blood cell disorders

White blood cell disorders can occur due to
malnutrition and liver disease. Lymphopenia
may be present in the patient with HIV disease.
Platelet disorders
Platelet disorders frequently are attributable
to the direct effect on the bone marrow by the
substance being abused or, as seen in alcoholrelated thrombocytopenia, are due to bone
marrow suppression. Splenomegaly caused by
portal hypertension also can cause a low
128
platelet count (thrombocytopenia), which is

due to enlargement of the spleen and abnormally high platelet storage. Thrombocytopenia also can be seen in cases of vitamin B12
and folate deficiency.
The African-American patient with sickle cell
disease or trait can be severely affected (inasmuch as the patient already has an impaired
oxygen delivery system) if other harm threatens the bone marrow.
Elevated heart rates can hinder the use of the
heart rate as a parameter in various detoxification protocols.
Pulmonary Disorders (Other

Than Infectious)
Pulmonary disorders are common in people
who abuse substances, in part because of the
high rate of nicotine use in this population
(Graham et al. 2003).
Aspiration pneumonia
Alcohol or other drug ingestion may reduce a
patients gag reflex, leading to the blockage of
the airways. Aspiration pneumonia occurs
when oro-pharyngeal secretions and/or gastric
contents enter into the lower airways. This serious condition may require prolonged hospitalization.
Asthma
Asthma, a chronic condition characterized by
exacerbations of bronchial spasm manifested
by wheezing, should be differentiated from
bronchospasm, which is related to inhaled
drugs and usually is self-limited. Treatment is
similar to that provided to patients who do
not use substances, with the addition of cessation of the substance use.
The patient with underlying chronic asthma
can be severely compromised if the use of a
smokeable drug causes exacerbation of an
already impaired system.
Chapter 5
Asthma medications can cause a significant
increase in heart rate, which can affect the
evaluation of withdrawal protocols that use
heart rate as one of the parameters.
ularly in hospitalized patients. Evaluation for

infections and the use of oxygen, steroids,
and inhalers is dictated by the clinical picture. During detoxification, if nicotine use is
not allowed, there can be significant effects
on drug levels (see chapter 4).
Chronic Obstructive
Pulmonary Disease
Neurologic System
Chronic obstructive pulmonary disease

(COPD) (emphysema, chronic bronchitis) frequently is due to cigarette use and the resulting alterations of the pulmonary immune system, inflammation, and destruction of lung
parenchyma. Presentation includes shortness
of breath on exertion, a cough producing
mucous, and wheezing.
African Americans who smoke cigarettes take
in more nicotine, and therefore more tobacco
smoke toxins per cigarette, than Caucasians
(Perez-Stable et al. 1998).
Daily marijuana smoking has been shown to
have adverse effects on lung function including a productive cough, wheezing, and excessive sputum production. However, the habitual marijuana-only smoker, in the absence of
alpha-1-antitrypsin deficiency, would have to
smoke four to five marijuana cigarettes per
day for a span of at least 30 years to develop
overt manifestations of COPD (Van Hoozen
and Cross 1997).
During nicotine withdrawal and cessation
treatment, different levels of nicotine absorption, as seen in some groups, will affect dosing
for nicotine replacement therapies (PerezStable et al. 1998). The patient with COPD,
especially if elderly, would be sensitive to the
sedating effects of many of the detoxification
protocol medications, especially the benzodiazepines, which may have to be reduced in
dosage to avoid respiratory depression and
worsening hypoxemia and hypercarbia
(decrease in oxygen and increase in carbon
dioxide). For smokers, always consider the
use of the nicotine replacement agents, partic-
The neurologic system of patients with substance use disorders is affected directly in the
toxic effects on cell membranes, effects on
neurotransmitters, associated metabolic
changes from other underlying disorders, and
changes in blood flow. Researchers have
found that the majority of those with an alcohol use disorder (75 percent) have some
degree of cognitive impairment (Goldstein
1987). Specific disorders found in patients
with substance use disorders can affect the
central nervous system and the peripheral
system. For example, a broad array of neuropathologic changes are seen in the brains of
people who use heroin. The main findings are
due to infections as a result of endocarditis or
HIV infection. Other complications include
hypoxic-ischemic changes with cerebral
edema, ischemic neuronal damage thought to
be due to heroin-induced respiratory depression, stroke due to thromboembolism, vasculitis, septic emboli, and hypotension.
Myelopathy occurs as a result of possible isolated vascular accident in the spinal cord,
and a distinct condition, leukoencephalopathy, has been described after the inhalation of
pre-heated heroin (Buttner et al. 2000).
As a final note, traumatic brain injury (TBI)
should always be considered in patients presenting with neurological impairment. People
who abuse substances are at high risk of falls,
motor vehicle accidents, gang violence,
domestic violence, etc., which may result in
head injury (Graham et al. 2003).
Unrecognized TBI can affect the treatment
outcome.
129
Wernicke-Korsakoffs
Syndrome
50mg every 6 hours for 24 hours) when detoxifying from alcohol.
Wernicke-Korsakoffs Syndrome is composed

of Wernickes encephalopathy and
Korsakoffs psychosis. Wernickes
encephalopathy is an acute neurological disorder with a triad of
Individuals with an alcohol use disorder show

an increase in seizures due to withdrawal,
metabolic insults such as hypoglycemia or
electrolyte imbalance, or head trauma. In one
study, researchers found that of 195 cases of
seizures in those with an alcohol use disorder,
59 percent were due to alcohol withdrawal, 20
percent to head trauma, and 5 percent to vascular disorders (Earnest et al. 1988).
Oculomotor dysfunction (bilateral abducens

nerve palsyeye muscle paralysis)
Ataxia (loss of muscle coordination)
Confusion
Evaluation of a first seizure should include a

neurological evaluation and evaluation for
head trauma. Metabolic etiologies, such as low
magnesium levels, should be considered.
Korsakoffs psychosis is a chronic neurological condition resulting from thiamine deficiency that includes retrograde and antegrade
amnesia (profound deficit in new learning and
remote memory) with confabulation (patients
make up stories to cover memory gaps).
Mayo-Smith (1997) has shown that benzodiazepines confer protection against alcohol
withdrawal seizures and thus patients with
previous seizures should be treated early with
this class of medications. The consensus panel
suggests that anti-epileptic drug therapy
should be considered in alcohol withdrawal
patients with multiple past seizures (of any
cause), a history of recent head injury, past
meningitis, encephalitis, or a family history of
seizures.
Thiamine initially is given parenterally and
then oral administration is the treatment of
choice. Always give thiamine prior to glucose
administration.
Alcohol and sedative

withdrawal seizures
Alcohol and sedative withdrawal seizures represent a significant medical challenge (Ahmed
et al. 2000), since no large clinical studies
have been conducted to firmly establish the
best treatment practices. Up to 90 percent of
alcohol withdrawal seizures occur in the first
48 hours and usually are single and nonfocal.
Repeated episodes of drinking and withdrawal are thought to predispose people to
seizures due to a kindling phenomenon (Post
et al. 1987). Patients with a history of withdrawal seizures are at greatest risk and
should receive prophylactic doses of a longacting benzodiazepine (e.g., chlordiazepoxide
130
Weakness and nystagmus are also seen in this

syndrome on examination of the eyes.
Wernickes encephalopathy is clearly related to
thiamine deficiency.
Clinicians should be aware that treatment of

the first seizure with benzodiazepines does
not prevent the likelihood of a second seizure
(DOnofrio et al. 1999). Slower medication
tapers should be considered when this condition co-occurs with detoxification.
Lorazepam, which can be used in patients
with liver disease, has been suggested as
appropriate, but it and other short-acting
benzodiazepines may not prevent late-occurring withdrawal seizures (Shaw 1995).
Dosages of anticonvulsant medications should
be stabilized before sedative-hypnotic withdrawal begins. Adequate treatment with a
long-acting benzodiazepine is effective in preventing withdrawal seizures (Mayo-Smith and
Bernard 1995). DOnofrio and colleagues
(1999) found that a one-time dose of the rela-
Chapter 5
tively shorter acting agent lorazepam also

reduced the risk of a subsequent seizure compared to placebo. However, in DOnofrios
study doses were small and the results were
limited somewhat by use in an emergency
room setting.
There is a higher than normal incidence of

hemorrhagic stroke and other intracranial
bleeding among patients with heavy alcohol
use, and a particular association of strokes
within 24 hours of a drinking binge (Altura
1986).
Older, first-generation anticonvulsants have

limitations in that they have only been studied in mild to moderate withdrawal, on rare
occasions they can cause serious hepatic and
bone marrow toxicities, and they can interact
with other classes of medication. Newer
drugs, such as gabapentin (Neurontin) and
oxcarbazepine (Trileptal), do not appear to
have these liabilities, but sufficient studies to
show this have not yet been done. There is little evidence that long-term use of phenytoin is
helpful in the patient who does not have an
underlying seizure disorder (Kasser et al.
2000). Medications that may lower the seizure
threshold, including phenothiazines, such as
prochlorperazine (Compazine), and several
antidepressants, such as bupropion, should
be used with great caution in the patient with
a seizure history.
The use of anticonvulsants, such as valproic

acid and barbiturates, has been studied in
pregnant women. Valproic acid is associated
with several malformations in the fetus. The
use of any anticonvulsant medication should
be discussed with the pregnant patient and
risks and benefits explained (Robert et al.
2001).
Cerebrovascular accidents
Cerebrovascular accident (stroke) can be seen
in alcohol and cocaine use, coagulation impairment, and severe uncontrolled hypertension.
Patients with recent cocaine/amphetamine use
may present with headaches, which could
represent subarachnoid and/or intracerebral
bleed, and therefore should be appropriately
evaluated (Buxton and McConachie 2000).
Heavy alcohol consumption increases the risk
for all major types of stroke by a variety of
mechanisms (Hillbom and Numminen 1998).
Nifedipine and verapamil have been shown to

prevent alcohol-induced vasospasm, which suggests a possible therapeutic approach to hypertension and stroke in the patient with heavy
alcohol use (Altura 1986).
Polyneuropathy
Polyneuropathy frequently is seen in
nutritional deficiencies that occur in the
patient with chronic
alcohol use.
Presenting signs and
symptoms include
lower extremity
pain, distal motor
loss, numbness or
tingling, and loss of
reflexes.
Polyneuropathy can
be seen in the
inhalation of h-hexane, methyl-n-butyl
ketone, and toluene
(Geller 1998).
Treatment of the
first seizure with
benzodiazepines
does not prevent
the likelihood of a
second seizure.
Hepatic encephalopathy
Hepatic encephalopathy is a toxic brain syndrome that results from the accumulation of
unmetabolized nitrogenous waste products in
a patient with severe liver dysfunction.
Presenting signs and symptoms include an
alteration in consciousness and behavior,
fluctuating neurologic signs such as a flapping
tremor (asterixis), and an elevated serum
ammonia level. Clinicians should evaluate
131
patients for precipitating causes, which

include the following:
GI hemorrhage
Electrolyte imbalance (metabolic alkalosis)
Infections
Drug Abuse 2000). Hepatitis B infections are

likely to present more often as a chronic
infection than as an acute-stage phenomenon.
Testing for chronic hepatitis B and C infection is appropriate during the detoxification
period.
Excessive diuresis (dehydration)

Use of sedatives
Increase of dietary protein intake
Followup for hepatitis B and C should be

arranged for after discharge from the detoxification setting. Vaccination is recommended
for hepatitis A and B in the patient with hepatitis C. The vaccination schedule is over a 6month period, so it needs to be done after the
detoxification program. If significant liver
disease is present, use of shorter-acting medication with less liver metabolism should be
considered. For more on infectious disease
and substance abuse, see TIP 6, Screening
for Infectious Diseases Among Substance
Abusers (CSAT 1993c).
Those patients who are infected with

Helicobacter pylori may be more prone to
hepatic encephalopathy (Duseja et al. 2003).
Clinicians should avoid the use of diuretics,
identify and treat factors that may have precipitated the
encephalopathy,
decrease dietary
Immunoprotein intake, and
use Lactulose to
compromised
decrease nitrogenous waste prodpatients may not
ucts via the GI
tract. Protocols
react to the
that use the benzodiazepines should
tuberculin skin
be adjusted to use
those specific medications that are
tests.
hepatically metabolized minimally or
not at all.
Infectious Diseases
The viral causes of hepatitis are multiple,
though the hepatitis B and C viruses are the
predominant causative agents. Hepatitis C
virus infection appears to be the most common form of infectious hepatitis in patients
with substance use disorders. At least 76 percent of patients who have used injection drugs
for less than 7 years are positive for hepatitis
C, while 25 percent of patients with alcohol
use disorders and those who do not inject
drugs show serologic evidence of infection
(Fingerhood et al. 1993; National Institute on
132
Endocarditis
Endocarditis is caused by the introduction of
various bacterial species into the vascular
system when the protective defense mechanisms of the skin are bypassed through injection. The patient frequently will present with
fever, cardiac murmur, anemia, enlargement
of the spleen, petechiae, and peripheral
embolic disease. The course can be subtle and
indolent to fulminant, and if untreated can
lead to a poor prognosis. In the patient who
uses drugs intravenously, the tricuspid valve
is affected in 70 percent of cases, followed by
effects on the aortic valve and the mitral
valve. Seventy-five percent of all cases are
caused by Staphylococcus aureus and up to
15 percent are caused by gram negative aerobic bacilli (Aragon and Sande 1994).
Endocarditis always should be suspected in
the febrile patient who uses intravenous
drugs. Patients who use drugs intravenously
are 300 times more likely to die suddenly
from infectious endocarditis than patients
who use drugs nonintravenously (Burke et al.
1997). Patients who use cocaine intravenously
Chapter 5
may have a higher rate of endocarditis as a

result of more frequent injections and the
reduced need to solubilize cocaine solutions
with heat (Chambers et al. 1987).
Bacterial pneumonia
Bacterial pneumonia can result from immune
system dysfunction, interference with normal
respiratory defense mechanisms (from alcohol
or smoked drugs), direct toxicity, or aspiration.
The treating physician should be aware that
the usual pathogens found in communityacquired pneumonia (i.e., Streptococcus
pneumoniae) may not be the causative agent
in pneumonias seen in patients dependent on
alcohol. Haemophilis influenzae, Klebsiella
pneumoniae, and other gram-negative
microorganisms must be suspected and treatment given until definitive culture results are
reported. Among patients who use parenteral
drugs, pneumonia is the most common reason
for admission to the hospital, accounting for
38 percent of all hospitalizations in this population (Marantz et al. 1987).
Careful use of respiratory depressants is recommended. Indications for hospitalization of
the patient with pneumonia (Neu 1994) include
the following:
Old age
Dehydration
infected patient presents with complaints of

cough (most common finding), bloody sputum, chest pain, fever, and weight loss.
Recent immigrants from countries where TB
is prevalent, socioeconomically disadvantaged
populations, homeless persons, people who
use illicit drugs, incarcerated people, and
people who live in areas where infection with
HIV is prevalent, are at increased risk for
this disease and should be tested. Furthermore, new strains of multidrug-resistant TB
are appearing, especially among the homeless
population (Borgdorff et al. 2000; Moss et al.
2000).
TB is endemic in many areas of the world
(Asia, Africa, and South and Central
America) (Gupta et al. 2004). As a public
health concern, testing all patients is of the
utmost importance, even more so for patients
from regions where TB is endemic. It is
important to remember that immunocompromised patients may not react to the skin tests
(anergy). Diagnosis is made with tuberculin
skin testing, sputum smears and cultures, and
radiographic findings. For more information
on dealing with tuberculosis in detoxification
and treatment settings see TIP 18, The
Tuberculosis Epidemic: Legal and Ethical
Issues for Alcohol and Other Drug Abuse
Treatment Providers (CSAT 1995i).
Skin infections
Tuberculosis
Skin infections frequently are seen as a result

of the intravenous administration of drugs.
Staphylococcus aureus and Streptococcus
pyogenes are frequently the infectious agents.
The patient presents with tenderness,
swelling, pain, erythema, and warmth in the
injection area. The type and route of antibiotic is determined by the infecting organism
and the extent and severity of the infection.
Clinicians should remember that injection
sites can be found virtually any place on the
body where there is access to the venous system.
Tuberculosis (TB) is caused by acid-fast rod

(Mycobacterium tuberculosis). Transmission
is by droplets spread through the air. The
Patients who use drugs intravenously,

patients with peripheral vascular disease, and
Vomiting and inability to take in oral fluids

and medications
Multilobar disease
Low white blood cell count
Respiratory acidosis
pO2 less than 55 mm Hg
Significant concomitant diseases
HIV
133
patients with diabetes (particularly with

infections of the feet) should all be evaluated
carefully for skin disease.
Sexually transmitted
diseases
Sexually transmitted diseases can be seen in the
form of urethritis, vaginitis, cervicitis, and genital lesions. These disorders are caused by a
variety of microorganisms, and a complete history and physical that includes examination of
the genitalia is indicated in all patients. The
clinical picture and cultures frequently can
guide the treatment protocols. Patients who use
drugs intravenously occasionally display a
false-positive serologic test for syphilis, possibly
due to a nonspecific reaction to repeated exposure of injected antigens (Hook 1992).
ing still should be educated about the risk

and prevention.
Due to increased virulence of syphilis in
patients who are HIV positive, as well as
increased resistance to the treatments indicated in the usual treatment protocols, all such
patients should be tested for syphilis and all
patients who test positive for syphilis should
be sent for HIV testing (McNeil et al. 2004).
If methadone is being used in withdrawal protocols, or maintenance is being continued, the
clinician should be aware that certain HIV
medications can cause an increased metabolism
of methadone:
Efavirenz (Sustiva)
Nevirapine (Viramune)
Lopinavir/ritonavir (Kaletra)
HIV/AIDS
134
Rifampin (a drug to prevent mycobacterium

avium complex, a serious bacterial infection,
in HIV-positive clients)
HIV/AIDS is a serious and prevalent medical

condition among persons with substance use
disorders, especially those who inject drugs
and may share needles with other users.
Patients with AIDS can present with a spectrum of complaints and illnesses ranging from
an asymptomatic history to complaints of
fever, enlargement of the lymph nodes, difficulty swallowing, diarrhea, weight loss, skin
lesions, shortness of breath (due to
Pneumocystis carinii pneumonia), headaches
(due to Toxoplasma gondii), seizures, and
dementia. As a rule of thumb, no complaint
in the patient infected with HIV should be
dismissed as irrelevant.

Persons With HIV/AIDS (CSAT 2000e) provides further information about substance
abuse treatment for patients with HIV/AIDS.
Gay men and patients who use drugs intravenously may be at higher risk for HIV/AIDS
than other groups; thus, testing or referral
for testing should be done and appropriate
counseling offered. All such patients should
be tested for HIV/AIDS or referred for testing. Some States, such as Colorado, require
that a risk assessment be administered to all
clients and that clients be advised of their
risk and referred for testing if they are at risk
for HIV/AIDS. Patients who decline HIV test-
Cancer occurrence is increased in people with

substance use disorders due to the carcinogenicity of the drugs used. Cigarette smoking
is linked to lung, larynx, oral cavity, esophagus, stomach, bladder, and pancreatic cancer. Heavy alcohol consumption is associated
with an increased incidence of oral, pharyngeal, esophageal, laryngeal, respiratory tract,
and breast cancer (Polednak 2005).
Synergism is seen with alcohol and smoking
being associated with even higher risks of
cancer (Fagerstrom 2002). A history of weight
Amprenavir (Agenerase)
Abacavir
Ritonavir
Other Conditions
Cancer
Chapter 5
loss could suggest many chronic diseases,

though cancer should be considered in the
differential. There may be an increase in
head and neck cancers in persons with heavy
cannabis use (Donald 1991). Liver cancer
may be seen in patients with hepatitis C and
those using anabolic steroids (Socas et al.
2005). There is a particular interrelationship
among alcohol intake, hepatitis C, and hepatocellular carcinoma (Yoshihara et al. 1998).
disorders appear to be particularly prone to

accidents of all kinds, with a spectrum of complications from head trauma to falls with fractures. Chronic pain frequently is seen in
patients as a result of trauma (treated or
untreated), poor health maintenance, or an
inability to deal with pain without drug use.
Chronic pain treatment and the issues of opioid
use have to be considered for each patient on
an individual basis.
Tricyclic antidepressants
The surgeon should

consider drug withdrawal in the differential diagnosis of
any physical or neuCertain HIV
rologic symptoms or
signs that emerge
during the periopermedications can
ative period. There
is a two- to threefold
cause an increased
increase in postoperative morbidity in
metabolism of
patients with alcohol
use disorders, the
methadone.
most frequent complications being
infections, bleeding,
cardiopulmonary
insufficiency, and
withdrawal complications (Tonnesen and Kehlet 1999).
Indomethacin
Olanzapine
Opioids may be used to control pain in the initial period of trauma. Detoxification protocols
should be started prior to anticipated surgery
and continued throughout the perioperative
period. Pain that causes an increased heart
rate, as well as postoperative temperature elevation, may impact the detoxification parameters.
Diabetes
Patients who use drugs intravenously may
experience infections that affect diabetic control, though any infection in any detoxification
patient needs to be addressed both from an
infectious disease and diabetic viewpoint.
Several medications can lead to impaired glucose tolerance and an elevated serum glucose
(Garber 1994). Some examples include
Thiazide diuretics
Clonidine
Glucocorticoids
Haloperidol
Lithium carbonate
Phenothiazines
Risperdol
Antidiabetic agents in concert with alcohol may
produce hypoglycemia and lactic acidosis.
Diabetes mellitus also is seen in patients who
present with new-onset hyperglycemia (elevated
glucose) or with a history of diabetes and poor
control.
Acute trauma/fractures
Acute trauma/fractures can be seen in any
patient with a substance use disorder due to an
altered level of consciousness or impaired gait
when intoxicated. Patients with substance use
Due to tolerance to opioids, the daily

methadone dose in a methadone-maintained
individual will not serve as an analgesic for
pain relief from surgical or other illnesses.
Full therapeutic doses of analgesic drugs
should be given to methadone-maintained
135
patients who have co-occurring painful conditions (CSAT 2005d; Ho and Dole 1979).
Since most medications for pain management
are drugs with a high abuse potential, programs may need to alter their policies regarding the use of such drugs. Pain patients do
not require detoxification from prescribed
medications unless they meet the criteria for
opioid abuse or dependence described in the
American Psychiatric Associations
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition. Treatments for
pain include physical therapy, transcutaneous
electrical nerve stimulation, and therapeutic
heat and cold.
Trials of nonsteroidal anti-inflammatory agents or
nerve block should
The effects of
be considered prior
to the use of highly
addictive and abusdrug toxicity and
able medications.
withdrawal often
The use of
acetaminophen in
can mimic
the patient with an
alcohol use disorder
psychiatric
always has been
questioned, espedisorders.
cially if there is evidence of liver disease. However, a
review article of the
medical literature
showed that repeated ingestion of a therapeutic dose of
acetaminophen over 48 hours by patients with
severe alcoholism did not produce an increase
in hepatic aminotransferase enzyme levels or
any clinical manifestations as compared to a
placebo group (Dart et al. 2000).
136
Treatment of
Co-Occurring
Psychiatric Conditions
Pharmacological agents can be used as indicated for co-occurring psychiatric conditions
in patients with substance use disorders.
Incidence of the co-occurrence of psychiatric
conditions and substance use disorders is
high; moreover, there is a higher rate of psychiatric conditions in patients dependent on
alcohol than that found in the general population (Kessler et al. 2003; Modesto-Lowe and
Kranzler 1999).
Comorbidity of substance use and co-occurring mental disorders serves to complicate
diagnosis and treatment for patients (Salloum
and Thase 2000). It is difficult to accurately
access underlying psychopathology in a person undergoing detoxification. The effects of
drug toxicity and withdrawal often can mimic
psychiatric disorders. For this reason, it may
be best to conduct psychiatric evaluations
after several weeks of abstinence; however,
this should be weighed against the time an
individual has been in detoxification and
what treatment plan is set up for him. Some
patients also present to detoxification while
taking medications to treat underlying psychiatric disorders, such as depression and anxiety. The risk of not treating a severe comorbid psychiatric disorder predisposes the
patient to relapse; the decision needs to be
weighed against the risk of prescribing medications when the clinician is not entirely certain that a comorbid condition exists. If a
period of recent extended abstinence exists,
the patients mental condition when abstinent
can be better evaluated.
Although it is the philosophy of some physicians to discontinue all psychiatric medications upon entering a detoxification program,
this course of action is not always in the best
interest of the patient. Abrupt cessation of
psychotherapeutic medications may cause
withdrawal symptoms or the re-emergence of
the psychiatric disorder. As a general rule,
Chapter 5
therapeutic doses of medications should be

continued through any withdrawal if the
patient has been taking the medication as prescribed. Decisions about discontinuing medications should be deferred until after the
individual has completed detoxification. If,
however, the patient has been abusing a medication or the psychiatric symptoms were
clearly caused by substance abuse, then the
rationale for discontinuing the medication is
strengthened. Finally, practitioners should
consider withholding medications that lower
the seizure threshold (e.g., bupropion or conventional antipsychotics) during the acute
alcohol withdrawal period, or at a minimum
prescribing a loading dose or scheduled taper
of benzodiazepine.
During detoxification, some patients decompensate and lapse into psychosis, depression,
or severe anxiety. In such cases, careful
observation of the withdrawal medication regimen is of paramount importance. If the
decompensation is a result of inadequate dosing with withdrawal medication, the appropriate response is to increase the dose of medication. If it appears that the withdrawal
medication is adequate, other medications
may be needed. Before choosing such an
alternative, it is important to take into
account additional considerations, such as the
side effects of the added medication and the
possibility of interaction with the withdrawal
medication.
A patient with psychosis may need to take
neuroleptics. Medications that have a minimal
effect on the seizure threshold are recommended, particularly if the patient is being
withdrawn from alcohol or benzodiazepines.
Small, frequent doses of Haldol, such as 1mg
every 2 hours, may be used until the patients
symptoms of psychosis begin to disappear.
The case for emergency use of antidepressants is weaker than for other psychiatric
medications because of the 2- to 3-week lag
time between initiation of medication and
therapeutic response. After detoxification,
the patients need for medication should be
reassessed. A trial without medications someCo-Occurring Medical and Psychiatric Conditions
times is the best way to assess the patients

need for the medication; however, it may not
be the best practice or in the best interest of
the patient, particularly for those with a serious mental illness. For more information on
working with patients with co-occurring substance use and mental disorders, see TIP 42,
Co-Occurring Disorders (CSAT 2005c).
Treatment for Co-Occurring

Conditions
The treatment of substance use disorders can
be difficult without adequate treatment of any
co-occurring mental disorders. For instance,
a patient with schizophrenia who is hallucinating and delusional, but who also abuses
substances, cannot participate in substance
abuse treatment without adequate control
over the psychosis. Likewise, patients with
mania who are euphoric and delusional,
patients who are depressed, or patients with
agoraphobia who also have a substance use
disorder, will have difficulty cooperating with
substance abuse treatment. Treatment of the
substance use disorder is necessary to
improve the course of both the substance
abuse and co-occurring mental disorder.
Psychotherapy should serve as one aspect of
rehabilitation, initially focused around
relapse prevention (Aviram et al. 2001).
Highly effective treatment programs may
include a combination of therapeutic techniques. Programs should be long-term and
approach recovery in stages. Drake and colleagues (2001) suggest that treatment for cooccurring substance use and other mental disorders include skill building, illness management, cultural sensitivity, and support to
patients for the pursuit of practical goals.
Limitations of pharmacological agents in persons with

substance dependence
Pharmacologic agents have limitations in the
population of persons with substance use dis-
137
orders. Medications may impair cognition and

blunt feelings, sometimes subtly. Clinicians
treating substance use disorders advocate
that clients need clear thinking and access to
emotions in order to make fundamental
changes in themselves. A person recovering
from a substance use disorder must take an
active part in changing attitudes and abandoning a long-held belief that alcohol or other
drugs can treat life problems and uncomfortable psychological states. Although these
are potential risks, the intent of pharmacotherapy is to enhance a persons ability to
sustain abstinence and benefit fully from concurrent psychosocial interventions and treatments. Still, many psychiatric disorders, if
untreated, result in mood, anxiety, or thought
disorders that prevent or retard the behavioral changes necessary to recover from substance use disorders.
Risks versus benefits of pharmacological
agents need to be considered carefully.
Untreated anxiety, mood, or thought disorders can be powerful relapse triggers, especially for people with a long-standing pattern
of relying on alcohol or other drugs to manage their symptoms. In many instances, the
benefits and reduced relapse risk that appropriate pharmacotherapy can provide far outweighs the risk of taking medications. Some
clinicians believe that the no pain, no gain
approach has far greater risk of interfering
with recovery than of promoting it. Symptoms
such as anxiety and depression in persons
recovering from substance use disorders
might be vital to recovery, and pharmacotherapy to treat such symptoms needs to be
considered carefully in this context.
Clinically, anxiety and depression can provide the motivation to change when the
patient otherwise has little awareness of the
need to alter behavior.
Standard of Care for

Co-Occurring
After detoxification and stabilization with
pharmacologic agents, the current treatment
of choice for substance use disorders is nonpharmacologic. Further, several studies have
shown that treating substance use disorders
with abstinence alone results in improvement
of the psychiatric syndromes associated with
the substance use (Anderson and Kiefer
2004). Severe syndromes induced by alcohol
that may otherwise meet criteria for major
depressive and anxiety disorders are best
classified as substance-induced disorders if
they resolve within days to weeks with abstinence. Likewise, manic syndromes induced by
cocaine resolve within hours to days, and
schizophrenia-like syndromes (e.g., hallucinations and delusions) induced by cocaine and
PCP often resolve within days to weeks with
abstinence.
Further studies are needed to confirm the
clinical experience that psychiatric symptoms
(including anxiety, depression, and personality disorders) respond to specific treatment of
the addiction. For example, cognitivebehavioral techniques employed in the 12-Step
treatment approach have been effective in the
management of anxiety and depression associated with addiction. Although challenging,
treatment of both addiction and co-occurring
psychiatric conditions has proven cost-effective in some studies (Goldsmith 1999).
Psychotropics for Co-Occurring

General aspects
Because alcohol and other drugs can induce
almost any psychiatric symptom or sign or
mimic any psychiatric disorder, their effects
always must be considered before a co-occurring condition diagnosis is established or
treated.
138
Chapter 5
With an understanding of the interactions

between substance use and other mental disorders, a rational approach can be applied to
the use of pharmacologic therapies in cooccurring conditions. The use of medications
for psychiatric symptoms should begin only
after the knowledge of the natural history of
the addictive disorder and other psychiatric
disorders is clarified. Further, it is important
to be able to identify the respective roles of
substance use and other mental disorders in
the generation of psychiatric symptoms.
Generally, substance-induced psychiatric
symptoms resolve within days to weeks of
abstinence. In many studies, the prevalence
rates for anxiety and affective disorders in
persons dependent on alcohol were not
greater than those for persons not dependent
on alcohol (Schneider et al. 2001).
A retrospective history of psychiatric symptoms often can lead to an inflated diagnosis of
these conditions because of rationalizations
regarding drinking and drug use by the individual. Typically, psychiatric symptoms are
emphasized by both the patient and the psychiatric examiner.
Longitudinal observation frequently clarifies
the role of alcohol and other drugs in the production of anxiety, affective, psychotic, or
personality symptoms, particularly if objective criteria are relied on in addition to the
subjective report of the person who is addicted. Also, specific treatment of substance use
disorders can result in improvement of mood,
psychotic behavior, and personality disturbances if related to the alcohol or other drug
use. Mood lability and personality states can
be a manifestation of substance use disorders,
and treatment of the addictive disorder can
lead to stabilization of these psychiatric
symptoms.
Furthermore, treatment plans and efficacy
may rely on the gender of the patient. Women
with a substance use disorder appear to have
higher rates of co-occurring mental disorders,
such as depression and anxiety, as well as
higher rates of physical and sexual abuse,
panic and phobia disorders, posttraumatic

stress disorder, victimization, and eating disorders. Deficits in the management of mood
disturbances may be self-medicated through
alcohol consumption in females. It has been
proposed that the outcomes of substance
abuse in women are different when compared
to those of men. For these reasons, the efficacy of treatment for substance use disorders
needs to be assessed independently for both
genders (Becker and Walton-Moss 2001;
Brady and Randall 1999).
Anxiety
Disorders
General
approach
Prevalence rates for
the co-occurrence of
anxiety and substance use disorders
in the general population range from 5
to 20 percent in epidemiologic and clinical studies
(Merikangas et al.
1996).
Major depressive
and anxiety
disorders are best
classified as
substance-induced
disorders if they
resolve within
days to weeks with
Some antianxiety
abstinence.
agents can oversedate and dull the
individuals reaction
to internal and external influences. Because
anxiety in recovery can be critically important for emotional growth, the individual will
feel a certain amount of anxiety to motivate
change in behavior, attitudes, and emotions.
(The expression emotional growth is related
to the anxiety or discomfort a recovering individual feels while undergoing the process of
change to reach a more mature state.) It is
important for the clinician to distinguish
between anxiety that can promote growth and
anxiety that can impair a persons ability to
make change. Adapting behavior in response
to anxiety or other emotion requires coping
139
skills that may not be available to persons in

early recovery. A fully symptomatic anxiety
disorder may significantly limit a persons
capacity to learn nonpharmacological coping
strategies. Medications with minimal addiction potential can be helpful and in some
cases necessary if patients are to make
progress in their recovery.
Depressants (e.g., alcohol) can produce anxiety during withdrawal, and stimulants (e.g.,
cocaine) can produce anxiety during intoxication. Because people with substance use disorders are in a relatively constant state of
withdrawal (it is
impossible to maintain a constant
blood level), they
regularly experiMedication is
ence anxiety as the
result of pharmacological withdrawal
indicated when
from dependence.
As the substance
the anxiety is
abuse becomes
more chronic, the
preventing the
anxiety produced
by withdrawal from
patient from
pharmacologic
dependence can
participating in
become increasingly
severe. Relapse
treatment.
and/or periods of
abstinence (sometimes prolonged
for weeks or
months) should be
considered (confirm
abstinence with laboratory drug testing, if
necessary) before the effects of depressant or
stimulant drugs in inducing anxiety can be
ruled out. It can take weeks or months for
these effects to subside completely, although a
period of only a few days to weeks often is
sufficient in clinical practice.
Treatment is indicated when the anxiety persists after adequate effort in a substance
abuse treatment program, or when the clinician suspects that anxiety is preventing the
140
patient from participating in treatment. A

thorough evaluation to assess whether the
individual is abstinent, involved in continuing
treatment, and/or attending self-help meetings
usually is necessary before a diagnosis of a
co-occurring psychiatric condition can be definitely established. After such an evaluation,
treatment of the anxiety disorder can proceed
separately from similar symptoms arising
from the addictive disorder.
Pharmacologic therapies
The ideal medication works against abnormal
anxiety but not against the normal anxiety
needed for recovery. Some of the physical
symptoms of anxiety include sweating,
tremors, palpitations, muscle tension, and
increased urination. Psychological symptoms
include nervousness, feelings of dread or
impending doom, unpleasant tenseness, and
many more.
The most common agents used in anxiety disorders are benzodiazepines and antidepressants. The benzodiazepines most frequently
used are alprazolam and lorazepam.
Diazepam and clonazepam are used less
often. Because the benzodiazepines can cause
significant problems in patients who are
addicted as well as in patients who are not
addicted, they generally are not recommended for people with substance use disorders or
for long-term treatment of anxiety or depressive disorders.
Antidepressants may be considered sooner if
depression is a known pre-existing condition
or historical experience and collateral information suggests a comorbid depression. Again
the risk of treating prematurely needs to be
weighed against the risk of not treating a condition that may prevent recovery from a substance use disorder. Antidepressants such as
imipramine and nortriptyline and selective
serotonin reuptake inhibitors (SSRIs) such as
fluoxetine (Prozac) have a low addiction
potential and can be used with relative safety.
They differ in their tendency to produce
sedation and anxiety and have a withdrawal
Chapter 5
syndrome of their own. Because of its anticholinergic properties, imipramine is more

sedating, but nortriptyline and the SSRIs can
produce anxiousness in some individuals and
sedation in others. Not all individuals react
the same way to these medications.
When medications are used, a specific target
symptom should be the focus. Also, medications should be tried in time-limited intervals,
such as weeks to months. A drug holiday
(i.e., a brief period where the patient stops
taking medications) should then be attempted
to see if the medication is still necessary.
The patient should be instructed that the
medications will not cure the addiction,
that treatment of anxiety will not control the
addiction, and that treatment of the addiction
will not necessarily ameliorate the anxiety disorder. In essence, the substance use disorder
must be treated independently of the anxiety
disorder and vice versa.
Depressive Disorders
General approach
Prevalence rates for the co-occurrence of
depressive and addictive disorders range
from 5 to 25 percent in epidemiologic and
clinical studies. Depressive disorders include
major depressive and dysthymic disorders,
which can occur independently with addictive
disorders, or similar depressive symptoms
can be induced by substance use disorders.
Major depressive disorder is more common in
older individuals and in women and can be
difficult to distinguish from substanceinduced depression.
Depression can be viewed as protective and
can be associated with healing in many conditions involving emotions. For example, a
grief reaction is an expected experience after
loss, with depression an essential emotion in
this process. Recovery from a substance use
disorder has been compared to a grief reaction because of losses (e.g., of the substance
or relationships based on substance use) sufCo-Occurring Medical and Psychiatric Conditions
fered by the patient with an addictive disorder. Likewise, and analogous to the role of
anxiety, depression also is a part of the healing process that the patient with a substance
use disorder experiences during recovery.
Depressant drugs (e.g., alcohol) can produce
depression during intoxication which often
resolves following abstinence. A survey of 69
adults with alcohol use disorders showed a
strong correlation between the reduction in
cravings for alcohol over 2 weeks of abstinence and the lifting of depressive mood. The
patients cravings were assessed with the
Obsessive-Compulsive Drinking Scale (OCDS)
and their depressive symptoms measured with
the Self-rating Depressive Scale (SDS).
Between day 1 and day 14, their cravings
score dropped nearly a third, while the scores
for severity of depression fell by about one
fourth. The correlation between the reduction
in cravings and the lifting of depression persisted after controlling for sex, age, duration
and extent of alcohol abuse, and the amount
of clomethiazole administered (Anderson and
Kiefer 2004).
Stimulant drugs (e.g., cocaine) can produce
depression during withdrawal. These effects
may be prolonged with certain drugs that
linger in the body (i.e., are stored in fat),
such as cannabis and benzodiazepines. These
drugs can produce depression or anxiety that
is indistinguishable from other psychiatric
causes of depression. Therefore, they must be
considered causative whenever depression is
present, and the possibility of addiction needs
to be assessed when these drugs are identified. While depression may persist for weeks
or months, it often resolves within days with
abstinence from these drugs.
The use of medication is recommended if the
depression persists beyond a few weeks of
drug withdrawal or arises during confirmed
abstinence (laboratory drug testing may be
necessary to confirm abstinence). The risk of
suppressing normal depressive processes dur141
ing recovery versus the benefit from suppressing depression that is interfering with
function should be weighed, as is the case
with anxiety disorders.
Antidepressants are the main treatment for
depression. The target symptoms are a sad
mood, tearfulness, appetite and sleep disturbances, and other neurovegetative symptoms.
Depression can be found in many conditions,
including a variety of psychiatric and medical
conditions. SSRIs are the drug of choice for
many physicians treating depressed patients
with substance use disorders. Although some
are costly, they provide adequate treatment
of depression with fewer side effects than
other medications commonly used (Thase et
al. 2001).
Depressive disorders are thought to have a
significant biological component, including
deficiencies in such central nervous system
neurotransmitters as serotonin, norepinephrine, and dopamine. Interestingly,
these neurotransmitters are also affected by
substances of abuse. These agents are thought
to act by increasing the activity of these neurotransmitters, ultimately alleviating depression and stabilizing mood.
Bipolar Disorders
General approach
Prevalence rates for the co-occurrence of
bipolar and addictive disorders range from 30
to 60 percent, depending on the population
studied, in epidemiologic and clinical studies
(Chen et al. 1998; Sallom and Thase 2000;
Sonne and Brady 1999; Strakowski and
DelBello 2000).
Mania is a condition associated with elevated
mood, grandiosity, hyperactive behavior,
poor judgment, and lack of insight. The
patient with mania will show excess such as
spending sprees, sexual promiscuity, intrusiveness, and abnormal alcohol and drug use.
A manic episode can follow, precede, or alternate with depressive moods.
142
Bipolar disorder may be complicated by the

influence of substances (Sonne and Brady
1999). The manic state can be produced by
stimulants (e.g., cocaine) during intoxication,
and from depressants (e.g., alcohol) during
withdrawal. A period of confirmed abstinence
usually is necessary before mood-stabilizing
drugs are started. Generally, a period of a
week or two may be required for the role of
drugs in inducing manic symptoms to be
properly assessed.
Mood stabilizers control bipolar disorders in
patients with or without co-occurring substance use disorder. These medications can
control either the manic or depressed phase,
or both.
Manic episodes can occur cyclically, alternatively, and concurrently with depressive
episodes. One theory of the pathogenesis of
bipolar disorder involves the neurotransmitter norepinephrine (i.e., excessive in mania
and deficient in depression).
Lithium is a natural salt, available in the carbonate form and slow release preparations.
Its exact mechanism of action is unknown,
but it can be effective in reducing or preventing the recurrence of manic and depressive
episodes. Lithium carbonate must be taken
daily in doses of 600 to 2,400mg to achieve
plasma levels in the 0.5 to 1.5-m equiv/L
range. It should be noted that studies have
shown that lithium has no conclusively positive effect on rates of abstinence in either
depressed or nondepressed patients.
Anticonvulsant mood stabilizers, such as
divalproex sodium and carbamazepine, can
be effective in controlling mania and, some
evidence suggests, in co-occurring addictive
conditions as well. Carbamazepine is known
to be as effective as some benzodiazepines in
inpatient treatment of alcohol withdrawal
and, because of its anticonvulsant properties,
it may be a good choice for treating those
patients at high risk of withdrawal seizures
Chapter 5
(Malcolm et al. 2001). One theoretical explanation for the mechanism of action for carbamazepine involves suppression of mood centers in the limbic system that act like seizure
foci. In this context, a kindling model has
been proposed for both mood and addictive
disorders (Gelenberg and Bassuk 1997).
Psychotic Disorders
General approach
Prevalence rates for co-occurrence of
schizophrenic and addictive disorders range
from 40 to 80 percent, depending on the population studied, in epidemiologic and clinical
studies.
Schizophrenia is a chronic illness characterized by bizarre thinking and behavior.
Hallucinations and delusions are positive
symptoms of the psychotic process, while
symptoms such as social withdrawal and
poverty of emotions are negative symptoms
(or deficit syndrome). Conventional neuroleptics are more effective for positive symptoms,
whereas behavioral, group, and individual
psychotherapy are more effective for negative
symptoms. New agents such as clozapine and
risperidone may be more effective in treating
both the positive and negative symptoms.
Psychosis can be caused by stimulant drug
use during intoxication and depressant
drug/alcohol use during withdrawal. A period
of weeks or months may be necessary to
assess the effects of substances of abuse, but
as with anxiety, depression, or mania, medications can be started at almost any time as
the psychosis is persistent and waiting is not
possible. Moreover, the greater the number of
psychiatric admissions, the greater the probability of a chronic mental disorder associated
with the co-occurring psychiatric disorder.
High- or moderate-potency neuroleptics (e.g.,
haloperidol or atypical agents) generally are
the agents of choice in the treatment of
schizophrenia. The clinical potency correlates
with the drugs ability to block the action of
the neurotransmitter dopamine at its postsynaptic receptor sites.
Adverse
Effects
Antianxiety
agents
While benzodiazepines are useful
in the short term,
their efficacy wanes
with long-term use,
probably because of
the development of
pharmacologic tolerance and dependence. It should be
noted that benzodiazepines can be
addicting, particularly in those already
addicted to other
substances.
A period of
confirmed
abstinence usually
is necessary
before moodstabilizing drugs
are started.
Antipsychotic agents
Antipsychotics can produce sedation and
hypotension (at times causing lightheadedness
in some individuals), particularly with postural changes. Conventional neuroleptics produce acute extrapyramidal reactions, which
include pseudoparkinsonism, dystonia, and
akathisia. Dystonia usually responds to treatment with anticholinergic drugs such as benztropine or diphenhydramine. Akathisia is
the subjective feeling of anxiety and tension,
causing the patient to feel compelled to move
about restlessly. This symptom usually
requires beta blocker, as a decrease in the
antipsychotic dose does not have the desired
effect. Alternatively, switching to risperidone
may accomplish the intended effect while
avoiding intolerable neurologic syndromes.
143
Antidepressants
Antidepressants, particularly the tricyclics,
can produce sedation, hypotension, syncope,
and other anticholinergic effects. The SSRIs
can produce anxiousness, sedation, insomnia,
and gastrointestinal upset. A withdrawal syndrome also has been reported with most
antidepressant medications.
The SSRIs are preferred in patients with
addiction and co-occurring psychiatric conditions because of their reduced side effect profile and low risk of dangerous drug interactions; for example, there are no anticholinergic effects on the senses and no risk of lethal
effects from overdose.
Cognitive State in Recovery

A person recovering from a substance use disorder must have a clear mind and a stable
mood. Medications have a tendency, sometimes subtly and other times obviously, to dull
the senses and thinking and blunt or disrupt
the emotions. People with substance use disorders must eventually change and control
feelings to remain abstinent and also to comply with psychiatric management. The ability
of a person with a substance use disorder to
144
use the 12 steps of Alcoholics Anonymous

(AA) and to accept psychiatric advice will
depend on clear thinking and emotional balance, which is stressed as central to the
recovery process in AA. In other casessuch
as patients with traumatic brain injuries
treatment venues should be adaptable to their
cognitive abilities.
Accordingly, the use of medications should be
conservative, taking into consideration the
pros and cons of their expected positive and
negative effects. Unfortunately, few psychiatric medications are totally free of moodaltering properties. However, the cognitive
state of individuals who have a serious mental
illness often is more distorted when not medicated appropriately. The very nature of their
illness is a disruption to their cognitive processes.
Dosing
Because of inherent susceptibility to drug
effects by people with substance use disorders,
it is important to use the lowest effective doses
possible. Also, the intervals for administration
should be selected to reduce effects on cognition and feelings.
Chapter 5
6 Financing and
Organizational
Issues
In This
Chapter
Preparing and
Developing a
Program
Working in
Todays Managed
Care Environment
Preparing for the
Future
Preparing and Developing a

Program
Developing a detoxification program is a major financial challenge,
whether the program requires building an entirely new organization
or is part of an existing treatment entity. The process of program
development requires careful planning, especially to ensure adequate
financial support for the operation. The decision to develop a detoxification program should be based on a well-developed strategic planning process (see chapter 2) and a clear understanding of what a
detoxification program entails. Because the new program will incur
major costs for office space, furniture, staff, computers, and other
equipment before clients can be provided with services and payment
can be received, significant amounts of initial capital may be needed.
As soon as the administrator or planner identifies a market need for
detoxification services, potential fiscal support and other resources
should be identified and checked to see if such support is likely and
sufficient. Both implementation and initial operating costs must be
covered. It may be possible to find strategic partners who will provide
resources, work with the program planner, provide office space, or
help obtain funding. Community organizations that see a need for
establishing detoxification and treatment services are likely partners.
Locally based foundations and businesses also may be approached for
assistance with developing a program, especially if a case can be made
to the potential funder that ongoing costs can be covered from operations.
It is important to have documented assurance from major referral
and payment sources that they will refer patients with information on
payment sources; that is, by the referral source, by a third party, or
145
by patients who have the documented financial resources to pay for detoxification treatment themselves. Signed contracts with
expected payors may be useful to ensure adequate cash flow and to establish a budget for
the new programs fee structure.
Identifying and recruiting strategic partners
is one of the most important steps in the program development process. Before and during
the program development process, administrators and planners should work closely with
potential referral and payment sources to
determine their needs and to see if the detoxification program will fit those needs.
Programs also will need to learn whether
referral sources are open to new partners, the
types of contracts they utilize, their timeframes for reimbursement, and the process
for negotiating a contract. Among useful tactics to employ is holding focus groups and
strategy meetings with individuals from
potential referral sources; these groups can
suggest the types of services they need and for
which they will reimburse. Potential referral
sources will be more invested in the program
if they are involved throughout the planning
process. All potential stakeholders should be
informed regularly of the developing plans
and milestones achieved.
Program planners should follow up on all
potential leads for both funding sources and
potential referral sources. Relationships with
referral sources are important to build and
maintain. Obviously, referral sources need to
be carefully assessed to ensure that they can
provide patients who have needs and
resources appropriate for the services the
program will provide. Leads for potential
sources of funding and referrals may include
the contacts made during a focus group process, public system payors and planners, private insurance plans, contracting agents for
private insurance (e.g., managed care organizations [MCOs]), and local employers large
enough to have employee assistance programs
(EAPs) or managed behavioral health plans
that cover detoxification services. Direct contact with the EAPs or managed behavioral
146
health plans may be necessary to ensure both

private sector demand for services and
appropriate reimbursement of the services.
Forming strategic alliances with other components of the treatment environment can be
both an important source for referrals and a
resource for clients with needs other than
detoxification. Vertical alliances facilitate
referrals up and down the continuum of care.
An alliance with a larger organization can
increase leverage when negotiating with an
MCO.
The Dramatically Changing

Pattern of Utilization of
The settings for detoxification services have
changed dramatically over the last decade, as
have patients primary substances of abuse. As
the setting for detoxification services has shifted from inpatient to outpatient, the primary
substance abuse problem of clients has shifted
from alcohol and cocaine/crack to heroin and
other opioids. This shift has created significant
opportunities in the market for detoxification
services for community-based and
entrepreneurial providers that are not part of
hospitals, or for freestanding detoxification
facilities that are owned by hospitals.
Changes in practice patterns and in the epidemiology of substance abuse in the last
decade have been dramatic. Between 1993
and 2000, the number of admissions to hospital inpatient settings for detoxification of
patients with a primary problem of alcohol
abuse declined by 79.6 percent. During the
same period, the total admissions to inpatient
hospital detoxification services declined by
69.3 percent, from 23.5 percent of total
detoxification admissions in 1993 to 8.8 percent of total detoxification admissions in
2000, while admissions to 24-hour free-standing detoxification units increased by the same
14.7 percentage points, from 60.5 percent of
total admissions in 1993 to 75.1 percent of
total admissions for detoxification services in
Chapter 6
2000. During this same period, the number of

alcohol admissions to free-standing clinics
decreased by 32.0 percent and the number of
cocaine/crack admissions decreased by 42.5
percent. Concurrently, heroin admissions (to
free-standing clinics) increased substantially
from just under a quarter of total detoxification admissions in 1993 to just over a third of
total admissions in 2000.
the reporting needs and performance requirements of each purchaser, to provide information that meets their requirements, and to
generate the appropriate bills/invoices.
Detoxification program administrators must
be knowledgeable about efficient business
practices, the use of data-based performance
measures, accounting, budgeting, financing,
and financial and clinical reporting.
Of course, these statistics reflect national

trends and regional differences in patterns of
both practice and substance abuse. Changes
in specific geographic areas will vary.
Prospective programs should carefully
research their own local market for detoxification services and should obtain data on
current utilization of and demand for detoxification in their local area before proceeding
with program development.
It also is important to reach out to other

potential sources of support such as foundations, board members, and local or
national corporate
Identifying and
donation programs
for any assistance
recruiting
that will help to
reduce costs,
strategic partners
increase revenue, or
improve productivity
is one of the most
and effectiveness
and aid in the success of the organizaimportant steps in
tion. Searching for
support does not end
the program
with ensuring initial
funding. Planners
development
must make good use
of the Internet to
process.
uncover potential
cash and in-kind
donations that can
supplement major funding sources, discussed
below.
Funding Streams and Other

Resources in the Substance
Abuse Treatment Environment
Substance abuse treatment and detoxification
services in the United States are financed
through a diverse mix of public and private
sources, with substantially more being spent
by the public sector. Public sources account
for 64 percent of all substance abuse treatment spending, a much higher percentage
than public expenditure for the rest of health
care (Coffey et al. 2001). The existence of
diverse funding streams presents both management challenges and opportunities for program independence and stability. However, a
program with only one major funding source
is financially and clinically vulnerable to
changes in its major sources budget and priorities, and this situation should be avoided.
Diversification of funding sources should be a
major goal for detoxification programs.
Usually, each funding stream has different
approval and reporting requirements.
Because of this, any new or existing detoxification program requires a fairly sophisticated
management and accounting system to meet
Financing and Organizational Issues
Entrepreneurial, for-profit programs may be

able to attract private capital. Not-for-profit
entities that are similarly entrepreneurial
may be able to take advantage of this potential source of funding through establishment
of a for-profit subsidiary. Detoxification programs in particular, as opposed to some other
areas of substance abuse treatment, may be
attractive candidates for private financing
because of their potential to serve privately
insured and self-pay patients. However,
acceptance of private capital usually carries
with it requirements for rapid growth in rev-
147
enues and profitability that may be difficult

to meet and may limit operational flexibility,
at least in the short term. In the longer term,
successful detoxification programs may be
able to generate profits.
Funding streams associated with public and
private health insurance often provide benefits to covered individuals that vary according
to whether or not the services are facilitybased and according to the level or
setting of care.
The Substance
Complexity arises
because coverage
Abuse Prevention
and reimbursement
depend both on
and Treatment
whether a service is
considered to be a
Block Grant
medical service or a
substance abuse
program is the
treatment service
and whether a sercornerstone of
vice is facility
based.
Federal funding
Many public and

private benefit
plans still classify
abuse treatment
substance abuse
detoxification as a
and detoxification
medical rather than
a substance abuse
programs.
treatment service.
In general, and
especially for
employer-based
coverage, benefits under a medical plan are
provided at higher reimbursement rates with
fewer limits and restrictions than are benefits
for substance abuse treatment (Merrick et al.
2001). Requirements for out-of-pocket payments by those covered under these plans
typically are lower under the medical portion
of a plan than under the substance abuse
treatment portion. However, it is important
to note that benefit plan features are but one
component of coverage; utilization management procedures continue to play a very
important role in a patients access to specific
for substance
148
services. Any episode of detoxification may be

denied reimbursement under a plan if medical necessity is not demonstrated to the satisfaction of the plan or if the service is provided at a higher level of care than is judged
medically necessary.
It is important to decide whether to make a
new detoxification program hospital-based,
facility-based, or office-based. Services that
are considered hospital- or facility-based, like
those in hospital outpatient departments,
often are eligible for higher payment rates
than office-based services to reflect their
greater capital and other overhead costs.
Similarly, hospital inpatient services often are
reimbursed at a higher payment rate than
outpatient services, but medical necessity
determinations also require patients to need
more intensive services. Sometimes, patient
copayments or coinsurance rates may be
higher for office-based services than facilitybased services. This is true for Medicare as
well as for other health insurance plans.
Detoxification programs that are parts of hospitals, affiliated with a hospital, or considered as a licensed facility themselves may be
eligible for higher rates of reimbursement
than are those that are considered to be outpatient programs with no facility license.
However, utilization management criteria to
authorize payment for admission to and continued stay in a hospital inpatient setting
require a significantly greater severity of
patient diagnosis than do criteria for admission and continued stay in a freestanding or
outpatient program. On the other hand, often
there are high barriers to obtaining a facility
license to open a freestanding 24-hour facility
or licensed outpatient detoxification facility.
Programs that are part of or affiliated with
hospitals also must contend with overhead
cost allocations from the hospital as well as
with oversight from hospital administrators
who may know little about substance abuse
treatment or detoxification. In addition, some
health insurance plans actually exclude coverage for hospital-based or freestanding facility-based detoxification programs and others
may subject admissions to such programs to
Chapter 6
more intensive review than admissions to

nonfacility-based detoxification programs.
Program planners should consider carefully
all alternatives; decisions concerning affiliation with a hospital or pursuit of a facility
license have far-reaching financial and political ramifications and should be made with as
much information as possible.
Following is a discussion of the key funding
streams and resources that are available for
programs providing detoxification services.
SAPT Block Grant

The Substance Abuse Prevention and
Treatment (SAPT) Block Grant program is
the cornerstone of Federal funding for substance abuse treatment and detoxification
programs. These funds are sent to the States
Single State Agency (SSA) for substance
abuse for distribution to counties, municipalities, and designated programs. Some of the
funds are subject to required set-asides for
special populations. Each program should
check to see if the clients it intends to serve
are eligible for block grant funding, either for
set-asides or for other funds. Each State
maintains its own criteria for eligibility and
the criteria and definitions vary greatly
among States. Multistate providers will need
to check specifically in each State in which
they operate.
The Substance Abuse and Mental Health
Services Administration (SAMHSA) provides
funding for substance abuse treatment and
prevention through the block grants as well as
a large variety of other mechanisms, including both discretionary grants and contracts.
A portion of the SAMHSA Web site is devoted
to various funding opportunities. (See
www.samhsa.gov/budget/index.aspx.)
The most recent available data indicate that
the SAPT Block Grant accounts for approximately 40 percent of public funds nationally
expended for prevention and treatment of
substance abuse (U.S. Department of Health
and Human Services 2003). Funds from the
block grant may come directly from the SSA
or be channeled through regional or county

intermediary agencies. Services may be paid
for through grants, contracts, fee-for-service,
and/or managed care arrangements. The
Childrens Health Act of 2000 mandated a
gradual transition from SAPT Block Grants
to Performance Partnership Grants (PPGs).
Providers should follow developments
through their SSA, which include
Changes in reimbursement. Treatment
purchasing systems may evolve over time;
managed care arrangements and requirements are increasingly common.
Performance outcome data. In accordance
with Federal legislation, PPGs eventually
will replace SAPT Block Grants and will
provide more flexibility for States as well as
require more accountability based on outcome and other performance data. The
(CSAT) and the States are establishing performance outcome measures for funding
programs under the block grants. All data
for core measures are collected from States
receiving PPG dollars.
Medicaid
Medicaid, administered by the Centers for
Medicare and Medicaid Services (CMS) in
conjunction with the States, provides financial assistance to States to pay for medical
care of specifically defined eligible persons.
Medicaid is being used by many States as a
vehicle for experimentation with public sector
managed care in an effort to expand medical
coverage to the uninsured. About 2 percent of
total Medicaid expenditures nationally are for
substance abuse treatment services (Mark et
al. 2003a) but Medicaid supports about 20
percent of national expenditures for substance abuse services (Coffey et al. 2001). The
level of expenditure varies greatly by State.
Medicaid is an entitlement program with several distinct eligible groups: low-income children, pregnant women, the elderly, and people who are blind or disabled, all or some of
whom can be enrolled in a detoxification program population. Some substance abuse
treatment programs will want to target pro149
grams to the Medicaid population; if the

States coverage and payment rates are minimal, however, other funders should be
explored in greater depth.
The reason for substantial variation in State
Medicaid expenditures and coverage is that
substance abuse treatment and rehabilitation
is an optional benefit under Medicaid that
States have the discretion to include or not
include in their Medicaid program. Medicaid
may pay for substance abuse treatment either
directly through fee-for-service arrangements
or through a managed behavioral health care
or other MCO with which it contracts. More
than one type of arrangement may exist within the same State. Rates of payment/reimbursement are determined by each State independently and may vary within the State
among the various coverage arrangements. If
a State decides to include benefits for substance abuse treatment in its Medicaid program, it can choose the precise services and
levels of care that will be reimbursed. The
services provided under managed care may
differ from those under fee-for-service
arrangements. Although most States offer
some coverage for detoxification services
under their Medicaid program (Office of the
Inspector General 1998), not all types or settings for detoxification programs are covered
in those States that do provide coverage.
Therefore, a State Medicaid program may
cover certain substance abuse treatment services but not cover detoxification services.
For more information, readers should contact
their State Medicaid office, or
www.cms.hhs.gov/home/medicaid.asp.
An important distinction of the Medicaid benefit structure since its inception has been the
exclusion of coverage for services provided in
an Institute for Mental Disorders (IMD),
defined as a facility with more than 16 beds
that treats mental disorders, including substance abuse, for individuals between the ages
of 21 and 64 (Rosenbaum et al. 2002).
Although services furnished by outpatient
detoxification programs are not excluded,
detoxification programs should be aware of
150
the IMD exclusion in their program planning

process.
The Medicaid Early Periodic Screening
Detection and Treatment (EPSDT) mandate
requires States to screen all children and adolescents on Medicaid for physical and behavioral health disorders. Further, EPSDT
requires that any needed medical treatment is
provided to children, even if the service is not
in the States Medicaid plan submitted to
CMS. Although the procedures and screening
tools vary by State, and there is significant
variation in their identification of substance
abuse issues, the EPSDT program is an
important entrance to substance abuse treatment for children and adolescents (Semansky
et al. 2003).
When available, Medicaid coverage offers the
following advantages:
It can provide significant treatment funding
for certain high-risk groups, such as lowincome mothers and adolescents.
Client copays traditionally have not been
required so the program receives the entire
negotiated fee without having to collect funds
from clients. (However, some States have
changed this provision due to budget crises.)
A Medicaid contract can provide a useful
lower limit for rate negotiations with commercial payors by essentially prohibiting
acceptance of contract terms with any other
purchaser at rates lower than those established for Medicaid.
Certification as a Medicaid provider also can
position the program to receive patients from
other public sector referral sources, making
it possible to obtain patients from sources
such as social services, indigent care funds,
and criminal justice systems.
The criminal justice and juvenile justice systems and drug court administrators typically
favor providers that are eligible for Medicaid
reimbursement because treatment of some
offenders can then be billed to Medicaid in
some States.
Chapter 6
Medicaid link to
Supplemental Security
Income
Supplemental Security Income (SSI) is a program financed through general tax revenues.
SSI recipients are one of the mandated populations for Medicaid, but specific provisions
vary by State. SSI disability benefits are
payable to adults or children who are blind
or have certain other disabilities that make it
impossible for them to work, who have limited income and resources, who meet the living
arrangement requirements, and who are otherwise eligible. Congress has excluded a primary diagnosis of substance abuse as a qualifying disability under the Social Security
Administrations programs, but if there is
another primary disability that qualifies the
person for SSI, a secondary substance abuse
diagnosis remains acceptable. Many SSI
recipients with a mental disorder diagnosis
have a co-occurring substance abuse
diagnosis.
Medicare
Medicare provides coverage to individuals
over age 65, people under the age of 65 with
certified disabilities, and people with endstage renal disease. Medicare supports about
8 percent of national expenditures for substance abuse treatment services. Medicare
may provide Part A coverage to clients in
detoxification programs that are based in hospitals certified by Medicare. However, detoxification programs that provide only a structured environment, socialization, and/or
vocational rehabilitation are not covered by
Medicare. Medicare imposes very strict
review requirements for detoxification programs based in hospitals and detoxification
programs that are considered to be partial
hospitalization programs, and for patients in
those detoxification programs. Alternatively,
Medicare may provide Part B coverage to
clients in detoxification programs with
Medicare-certified medical practitioners;
however, clients whose services are reimFinancing and Organizational Issues
bursed under Part B are required to pay 50

percent of Medicare-approved amounts. For
more information, contact the Social Security
Administration, Medicare provider enrollment department, State Medicare services, or
see www.cms.hhs.gov/home/medicare.asp.
Medicare link to Social

Security Disability Insurance
The Social Security Administration provides
Social Security Disability Insurance (SSDI) to
individuals and certain members of their family if they have
worked long enough
and paid Social
Medicaid supports
Security taxes.
Recipients of SSDI
about 20 percent
benefits are covered
by Medicare followand Medicare
ing a 2-year waiting
period. SSDI is a
supports about
program financed
with Social Security
8 percent
taxes paid by workers, employers, and
self-employed perof national
sons. In order to be
eligible for a Social
expenditures for
Security benefit, the
worker must earn
substance abuse
sufficient credits
based on taxable
treatment
work. Disability
benefits are payable
services.
to disabled workers,
disabled widow(er)s,
or adults disabled
since childhood, who are otherwise eligible. A
substance abuse diagnosis was excluded by
Congress as a qualifying disability for SSDI,
but a secondary substance abuse diagnosis is
acceptable if the person is qualified by another primary diagnosis, such as mental illness,
which often co-occurs. For more information
see the Social Security Administrations Web
site at www.ssa.gov/dibplan/index.htm.
151
State Childrens Health

Insurance Program
The State Childrens Health Insurance
Program (SCHIP) provides funds for substance abuse treatment of children and adolescents in many States. This program provides low-cost health insurance for children
of low-income families who are not eligible for Medicaid.
Substance abuse
States have the
option of providing
treatment and
SCHIP benefits
under their existing
Medicaid program
detoxification
or designing a separate childrens
services in the
health insurance
program entirely
United States are
separate from
Medicaid. If the
funded through a
program is part of
Medicaid, then the
diverse mix of
substance abuse
benefits will mirror
public and private
those under
Medicaid. If the
State designs its
sources.
own program, CMS
has promulgated a
set of rules to
ensure that coverage meets minimum standards. A States Alcohol and Drug Abuse
Agency also may be able to provide information on resources available for treatment of
transition-age youth who have exceeded the
maximum age for the SCHIP program in the
State. For more information see
www.cms.hhs.gov/home/schip.asp or the State
SCHIP program office.
Navy, and Air Force with networks of civilian

healthcare professionals. TRICARE consists
of TRICARE Prime, where Military
Treatment Facilities are the principal source
of health care; TRICARE Extra, a preferred
provider option; and TRICARE Standard, a
fee-for-service option that replaced the program formerly known as CHAMPUS. The
TRICARE Extra and Standard benefits
include treatment for substance abuse, subject to preauthorization requirements, but
programs will need to check to see if detoxification programs are eligible or preauthorized
under TRICARE managed care arrangements. TRICARE is run by managed care
contractors, each of whom may have different
authorization procedures. For more information see www.tricare.osd.mil.
Indian Health Service

The Indian Health Service (IHS) is an agency
within the Department of Health and Human
Services that operates a comprehensive health
service delivery system for approximately 1.6
million of the Nations estimated 2.6 million
American Indians and Alaska Natives. Most
IHS funds are appropriated for American
Indians who live on or near reservations.
Congress also has authorized programs that
provide some access to care for Indians who
live in urban areas. IHS services are provided directly and through tribally contracted
and operated health programs. Health services also include health care purchased from
more than 9,000 private providers annually.
The IHS behavioral health program supports
alcoholism and other drug dependency treatment, detoxification, rehabilitation, and prevention services for individuals and their
families. For more information see
www.ihs.gov.
TRICARE
TRICARE is a regionally managed health
care program for active duty and retired
members of the uniformed services and their
families and survivors. TRICARE supplements the healthcare resources of the Army,
152
Department of Veterans
Affairs
The Department of Veterans Affairs provides
the Civilian Health and Medical Program of the
Veterans Administration to eligible beneficiaChapter 6
ries. Medically necessary treatment of substance abuse is a covered benefit; beneficiaries

are entitled to three substance use disorder
treatment benefit periods in their lifetimes. For
more information see http://www.va.gov/hac/
forbeneficiaries/champva/champva.asp.
Social Services
Funding for substance abuse treatment,
which may include detoxification services,
also may be available through arrangements
with agencies funded by the U.S. Departments of Labor, Housing and Urban
Development (HUD), and Education (ED).
Some Federal sources of funding for substance abuse treatment under these programs
may prohibit use of funds for medical services. However, services performed by those
not in the medical profession (e.g., counselors, technicians, social workers, psychologists) and services not provided in a hospital
or clinic (including 24-hour care programs)
may be considered nonmedical. The precise
definition of medical under some of these
Federal programs may be determined by each
State individually, so administrators need to
check with their State authorities to determine exactly which services may be funded
through these sources. Even if funding for
detoxification services is not available
through these programs, programs may be
able to link their clients to them for support
for services that enable them to initiate and
complete treatment successfully. Opportunities include the following:
Temporary Assistance to Needy Families
(TANF). Under the TANF programs, each
State receives a Federal block grant to fund
treatment for eligible unemployed persons
and their children, usually women with
dependent children. Services that overcome
barriers to employment (e.g., substance
abuse treatment) are eligible for formula
grantswith one quarter of the money allocated to local communities through a competitive grant process. The funding channels vary by State. Funds may be directed
through Private Industry Councils,
Workforce Investment Boards, Workforce
Development Boards, and similar bodies at

the State and community levels. Although
States may not use TANF funds for medical services, States have considerable latitude in the definition of medical, and
have used TANF funds to support the following substance abuse treatment services:
screening/assessment, detoxification, outpatient treatment, non-hospital residential
treatment, case management, education/
prevention, housing, employment services,
and monitoring (Rubinstein 2002). Even if
these funds are not available for substance
abuse treatment in a State or program, the
programs clients may be able to access this
source of assistance for employment training, child care, and other support needs.
For more information on TANF, see
www.acf.hhs.gov/programs/ofa/.
Social Services Block Grant. Under Title
XX of the Social Security Act, the
Administration for Children and Families
provides a block grant to each State for the
purpose of furnishing social services. Funds
may not be used for medical services
(except initial detoxification of an individual who is alcohol or drug dependent). In
2002, these funds provided close to $8 million for substance abuse treatment in 14
States (Administration for Children and
Families 2002).
Public housing. HUD funds substance
abuse treatment of public housing residents
under the Public Housing Drug Elimination
Program. HUD awards grants to public
housing authorities, tribes, or tribally designated housing entities to fund treatment.
Funds are channeled to local public housing
authorities, which contract with service
providers. In addition, special housing programs are available for people who are
homeless and have substance use disorders.
For more information see www.hud.gov.
Vocational rehabilitation. Federal ED
funds support services that help people with
disabilities participate in the workforce.
Treatment of substance use disorders is eligible for funding. Funds are channeled to
153
the State agencies responsible for vocational

rehabilitation. For more information see
www.ed.gov.
Childrens protective services. Title IV of
the Social Security Act provides funding for
foster care and services to prevent child
abuse and neglect. Eligible services include
substance abuse treatment for parents who
are ordered by a court to obtain treatment
and are at risk for losing custody of their
children. Medicaid also covers these children, as they are a mandatory eligibility
group. For more information see
www.acf.hhs.gov/programs/cb/index.htm.
Ryan White. The Federal Ryan White
CARE Act, enacted in 1990, provides
health care for people with HIV disease.
Under Title I of the Ryan White CARE Act,
which provides emergency assistance to
Eligible Metropolitan Areas that are most
severely affected by the HIV/AIDS epidemic, funds are available for substance abuse
treatment. Over 500,000 people are served
through this program each year. For more
information see www.hab.hrsa.gov.
Criminal justice/juvenile
justice (CJ/JJ) systems
Both State and local CJ/JJ systems purchase
substance abuse treatment services. The manner in which these systems work varies across
locales. The following are common components
of these systems:
State corrections systems may provide
funds for treatment of offenders who are
returning to the community, through parole
offices, halfway houses, or residential correctional facilities.
Community corrections systems may
include a system of presentence diversion or
parole services, including drug court, that
may mandate substance abuse treatment in
lieu of incarceration.
Community drug courts may send low-risk,
nonviolent offenders to substance abuse
treatment in lieu of incarcerationpro-
154
grams can be under contract to provide this

treatment.
Correctional residential facilities serve
offenders returning from a State correctional system; the programs may extend contracts for substance abuse treatment to prevent relapse of treated offenders.
Juvenile court systems may provide contracts to programs with expertise in treating
adolescents to treat juvenile offenders in
correctional facilities or who are otherwise
involved in the criminal justice system.
Providers should understand the culture, values, and needs of the CJ/JJ system so they
can develop responsive services for this special needs population. For more information,
see TIP 21, Combining Alcohol and Other
Drug Abuse Treatment With Diversion for
Juveniles in the Justice System (CSAT
1995b), TIP 30, Continuity of Offender
Treatment for Substance Use Disorders From
Institution to Community (CSAT 1998b), and
Adults in the Criminal Justice System (CSAT
2005b).
Byrne Formula Grant

Program
The Byrne Formula Grant Program awards
grants to States to improve the functioning of
the criminal justice system. Grants may be
used to provide rehabilitation of offenders
who violate State and local laws. One of the
26 Byrne Formula Grant purpose areas is
providing programs that identify and meet
the treatment needs of adult and juvenile
offenders who are drug and alcohol dependent. However, the availability of Byrne
Formula Grant funds depends on annual
Congressional appropriations and declines
have been proposed for funding in recent
years. For more information see
www.ojp.usdoj.gov/BJA/grant/byrne.html.
Chapter 6
County and local

governments
County and local governments often contract
for the delivery of substance abuse treatment
services using locally available funds. The
annual availability of these funds depends in
part on State fiscal conditions.
Schools
Local public schools may be a source of funding for assessments; however, they rarely pay
for ongoing treatment. Some services may be
reimbursable under the special entitlements for
children with disabilities.
Private Payors
Private sources of revenue include a range of
entities from large MCOs to local or selfinsured national employers. Most health
plans offered by large employers operate
under managed care arrangements.
Sometimes, a health plan may cover some
substance abuse treatments under the mental
health benefit portion of their plan; others
may provide coverage through the medical
component. In many cases, substance abuse
treatment benefits, when offered, are provided through Managed Behavioral Healthcare
Organizations (MBHOs) (see Working In
Todays Managed Care Environment, p.
157, for a more detailed discussion of managed care arrangements). Because substance
abuse coverage is a minor cost to employers,
accounting for about 0.4 percent of the cost
of health insurance overall (Schoenbaum et
al. 1998), it may be difficult to get employers
attention, despite the high profile that substance abuse problems sometimes present. In
general, three broad categories of private
funding may be distinguished:
Contracts with health plans, MCOs, and
MBHOs.
Direct service contracts with local employers.
Local employers may contract directly with
substance abuse services providers if the ben-
efits offered by their health plans are inadequate.

Contracts with EAPs. Some employers have
EAPs that can provide direct service contracts for a particular detoxification program.
Contributions
By developing relationships with people in the
community, an administrator can find new
sources for support of capital and operations.
Even if a source is reluctant to provide funds to
support treatment
services directly,
other aspects of proMany public and
gram development,
organizational
private benefit
growth, and operations or equipment
may be eligible for
plans still classify
support. A variety of
support may be
detoxification as a
available from
sources in the commedical rather
munity, ranging from
financial support to
than a substance
donations of time,
expertise, used or
abuse treatment
low-cost furniture
and equipment, and
service.
space for a variety of
activities. Some
potential sources
include
Fundraisers. People who do fundraising
can help the program develop a campaign.
Many States and the District of Columbia
require that charitable organizations register and report to a governmental authority
before they solicit contributions in their
jurisdiction (a list of State regulating
authorities is available at
www.labyrinthinc.com/index.asp).
Foundations and local charities. A program may qualify as a recipient of funds for
capital, operations, or other types of support such as board development from foun-
155
dations, the Community Chest, United Way

(national.unitedway.org), or other
charities. For more information see
www.fdncenter.org.
Alumni. Graduates from a program may
donate money to the program or provide
support for clients.
Internships. Local colleges and universities
may need internship slots for their students
who are planning careers in human services.
Volunteers. Some programs use volunteers
in various capacities. Sources include local
retirement organizations and faith-based
agencies.
Community groups. Faith-based agencies
and community centers may let the program
use rooms for meetings, alumni groups,
recovery support groups, or classes.
Community groups can contribute reading
materials, clothes, toys for clients children,
furniture, or computers.
Local stores and vendors. Local businesses
may contribute useful supplies such as
snacks, office supplies, or even computers.
Research funding
In addition to SAMHSAs other roles, such as
technical assistance, helping communities use
research findings to implement effective treatment programs, and funding of prevention and
treatment, the institutes of the National
Institutes of Health conduct research on best
practices in substance abuse treatment.
The Research Assistant
(www.theresearchassistant.com) may be a helpful source for information. For current funding
opportunities, visit the National Institute on
Drug Abuse Web site (www.nida.nih.gov) and
the National Institute on Alcohol Abuse and
Alcoholism Web site (www.niaaa.nih.gov).
Grants
Government agencies and private foundations
offer funding through competitive grants.
Grant money usually is designated for discrete
156
projects, such as creating a videotape on family

issues, providing childcare services in a program for women, enhancing the cultural competence of staff members, or treating underserved populations.
Writing grant applications requires special
skills. A program can hire a consultant to
write the application or use its own planning
or research staff, if available. Successful
grant applications address areas of genuine
need, propose ideas worthy of support,
express these ideas well, and explicitly follow
the requirements of the request for application or proposal. To design a fundable project, the program may need to establish links
with other resources. Each donor agency or
foundation has its own application format
and requirements that should be followed
exactly. It is especially important when using
a consultant to have program staff closely
involved in the process of developing a grant
application to ensure that affirmations in the
application are completely aligned with agency capabilities. Programs that fail to involve
their own staff in the grant application process risk falling into the implementation
trap when a grant is awarded for projects
they are not prepared to perform. SAMHSA
offers a variety of resources to assist community-based organizations and others in developing successful grant applications. See the
text box on page 157 for sources of information on grants for treatment and detoxification programs.
Self-pay patients
Some patients pay for some or all of a course
of treatment themselves, without seeking
reimbursement from a third-party payor.
These patients may have no or inadequate
third-party coverage for substance abuse
treatment and are not eligible for public payment sources. Some patients who have coverage may prefer to pay out of their own pockets due to concerns about the confidentiality
of their information with their employer or
others.
Chapter 6
Where To Get Information on Grants

SAMHSA provides information about the grants it provides at www.samhsa.gov/grants/index.html.
Information on grants throughout the Federal government is available from www.grants.gov.
The Web site www.cybergrants.com provides information about corporate foundations.
The National Center on Addiction and Substance Abuse at Columbia Universitys Web site at
www.casacolumbia.org provides links to several helpful sites.
The Substance Abuse Funding Week provides public and private funding announcements for alcohol,
tobacco, and drug abuse programs. It is available by subscription in print or on the Web at
www.cdpublications.com/pubs/.
Several useful publications on grant seeking and grant writing can be ordered from www.grantsandfunding.com.
The Grantsmanship Center at www.tgci.com offers some useful information.
The Non-Profit Resource Center, www.not-for-profit.org, has information on a variety of funding
sources.
Working in Todays
Managed Care
Environment
All healthcare providers, including those who
provide substance abuse treatment services,
increasingly operate in a world in which care
is managed in all sectors, both public and private. Among individuals covered by employer-sponsored benefits in 2003, 95 percent
were covered under managed care arrangements (Kaiser Family Foundation and Health
Research and Educational Trust 2003). The
penetration of managed care into employersponsored health plans is relatively new; as
recently as 1993, 46 percent were covered by
indemnity plans. It is estimated that more
than 160 million Americans have their behavioral health care (treatment for substance use
and mental disorders) covered by a managed
behavioral health care organization (Oss and
Clary 1999). Although managed care penetration is lower in public programs than in
employer-sponsored programs, it is still significant; in 2002, 58 percent of the Medicaid
population was enrolled in managed care
arrangements (CMS 2002). Many States also
operate MCOs not connected with Medicaid
for provision of substance abuse treatment

services.
Behavioral health care carve-outs, so named
because management of substance abuse
treatment and mental health benefits are separated (carved out) from the provision and
management of other healthcare services, are
now the dominant approach to managed care
for mental health treatment. However, this is
not the case for substance abuse; many
behavioral health carve-outs retain substance
abuse coverage in the medical MCO. The
carve-in approach, which theoretically
integrates traditional medical services with
services for substance use and other mental
disorders, is re-emerging but as of 2004 was
still relatively rare. Even when health plans
carve-in substance abuse services, they often
use a subcontracted specialty vendor or a
separate internal division with specialty
expertise to manage the carve-in benefits.
MCOs are becoming more prevalent in the
public sector. In 2002, 51 percent of all substance abuse treatment facilities had contracts with MCOs and even 39 percent of
facilities owned by State and local governments had such contracts (Office of Applied
Studies 2002b). By 1998, all but four States
had implemented some form of managed
157
behavioral health care in their public sector

treatment programs. However there is wide
variation among States and large counties in
the extent and form of reliance on managed
care and in the vendors who operate such
programs on behalf of government or private
entities.
A distinct terminology has evolved in the
managed care industryterms such as capitation, network, or staff-model as well as a
host of acronyms.
It is estimated that
Contracts
Are Primary
Tools
Managed care
arrangements have
four fundamental
million Americans
aspects with which
all program adminhave their
istrators should be
familiar. First, an
behavioral health
arrangement begins
with a managed
care contract that
care (treatment
specifies the obligations of each party.
for substance use
It should be noted
that small communiand mental
ty providers may
have little or no
disorders) covered
negotiating leverage
in the contracting
by a managed
process; their only
decision may be
behavioral health
whether or not to
accept what is
offered, including
care organization.
the rate of payment
and all other contract provisions.
Nevertheless, a clear and detailed understanding of the contract is required to ensure
successful performance. One key aspect of
any managed care contract is the financial
arrangement between the parties, including
the basis for payment and the amount of risk
more than 160
158
assumed by each party, if any. Of course,

some managed care contracts are not riskbased. It is important to have someone with
expertise and experience in managed care
contracts and financing examine any proposed contract and make certain that the
financial components of the arrangement are
well understood by the program staff who
have financial responsibilities.
Secondly, by negotiating and signing a managed care contract, a detoxification program
or its parent agency becomes a member of
that MCOs managed care network. MCOs
generally have a network of contracted and
credentialed providers who supply services at
a negotiated rate to members who are
enrolled in the plans. Each organizational
member of the network must satisfy the
MCOs minimum requirements for licensure
of staff, programs, and facilities to be eligible
for a managed care contract.
The third fundamental aspect of managed
care arrangements is the requirement for performance measurement and reporting. All
MCOs apply a wide range of standard performance measures to each of their contracted
providers and may have financial or referral
incentives or disincentives associated with
measured performance.
Finally, the fourth aspect involves utilization
management and case management. These
tasks generally are performed by MCO staff,
typically nurses or social workers, with
supervision from Ph.D. clinicians or physicians. The staff makes a determination of
what services are medically necessary and
therefore eligible for health plan reimbursements. Utilization management compares a
providers proposed treatment plan with similar or expected plans for individuals with similar conditions and diagnoses. The utilization
management approach may vary not just by
MCO but by MCO customer, with some customers preferring that utilization be highly
scrutinized and meet the test of medical
necessity and others preferring that the MCO
use a light touch in managing utilization. If a
treatment plan from a detoxification program
Chapter 6
does not meet criteria for medical necessity, it

is likely to be denied and referred to a higher
level clinician for review, delaying approval
and payment. It makes sense to obtain each
MCOs protocols, as well as any specific
arrangements and benefit plans for customers
whose employees or enrollees are in the
detoxification programs client population.
Case management programs operated in the
private sector often are utilization review
programs rather than the clinical case management programs typical in the public sector. Moreover, the process of case management in the private sector often differs from
the one found in traditional public sector
mental health or substance abuse treatment
agencies. Instead, it primarily involves telephone contact, usually with a nurse, in highrisk or high-cost cases. Case management
usually is not performed onsite or in person
in MCOs unless under contract to a public
agency that requires this. If a detoxification
program client has a public sector and a managed care case manager, the detoxification
program will have to interact with both to
obtain initial and continuing approvals of
treatment in what is called a case or utilization management program.
In general, programs will be required to
obtain utilization management approval
and/or case management approval for any
proposed treatment plan before they can bill
the MCO. Programs will have to bear the cost
of pursuing denials and requesting exceptions
as well. The more the programs staff can
develop a relationship with the MCOs utilization management and case management staff,
the more they will learn about the internal
criteria and protocols that drive approval or
denial decisions and the more latitude they
will have to request special arrangements for
a particular client. Most MCOs and MBHOs
have Web sites with provider portals. Once a
program identifies the name of the managed
care plan from which payment is to be
requested staff should be sure to check its
Web site. Some managed care plans offer
electronic data interchange with network

providers to facilitate claims submission.
Elements of Financial Risk in

Managed Care Contracts
Cost of services
To assess and negotiate a managed care contract and to monitor a programs performance under that contract, it is imperative to
know what it costs the detoxification program
to provide each unit of service that is produced. The cost of services includes staff time
spent with clients, administrative time spent
on meetings and paperwork, and capital and
operating expenses. Only when the actual cost
of delivering a unit of a particular service is
known can an agency negotiate a reasonable
rate for specific services when negotiating
contracts and a fiscally prudent arrangement.
Determining the cost of services often entails
many challenges but is absolutely essential in
the current environment of accountability.
See the text box on page 160 for a list of
resources from the literature. Following are
the recognized but evolving cost methodologies developed specifically for substance
abuse services:
The first systematic cost data collection
method, the Drug Abuse Treatment Cost
Analysis Program (DATCAP) (French 2003a,
b), was developed in the early 1990s by
economists at Research Triangle Institute
(French et al. 1997). The Treatment Services
Review used with DATCAP provides unit service costs (French et al. 2000).
The Uniform System of Accounting and
Cost Reporting for Substance Abuse
Treatment Providers is a cost estimation
method developed about the same time by
CSAT (1998d).
Another estimation approach has been
developed by Yates (1996, 1999): the
CostProcedureProcessOutcome
Analysis.
Anderson and colleagues (1998) have developed a cost of service methodology.
159
Resources on Service Costs

Anderson, D.W., Bowland, B.J., Cartwright, W.S., and Bassin, G. Service-level costing of drug abuse
treatment. Journal of Substance Abuse Treatment 15(3):201211, 1998.
Center for Substance Abuse Treatment. Measuring the Cost of Substance Abuse Treatment Services: An
Overview. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998.
Center for Substance Abuse Treatment. Uniform System of Accounting and Cost Reporting for
Substance Abuse Treatment Providers. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 1998. http://www.icpsr.umich.edu/SAMHDA/SATCAAT/system-accounting.pdf.
Center for Substance Abuse Treatment. Summary Report on Assessment and Measurement of
Treatment Costs. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000.
http://www.icpsr.umich.edu/SAMHDA/SATCAAT/summaryreport.pdf.
Dunlap, L.J., and French, M.T. A comparison of two methods for estimating the costs of drug abuse
treatment. Journal of Maintenance in the Addictions 1(3):2944, 1998.
Flynn, P.M., Porto, J.V., Rounds-Bryant, J., and Kristiansen, P.L. Costs and benefits of methadone
treatment in DATOSPart 1: Discharged versus continuing patients. Journal of Maintenance in the
Addictions 2(1/2):129150, 2003.
French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): Program Version. 8th ed.
Miami, FL: University of Miami, 2003. http://www.datcap.com/program.htm.
French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): Users Manual. 8th ed. Miami,
FL: University of Miami, 2003. http://www.datcap.com/usersmanual.htm.
French, M.T., Dunlap, L.J., Zarkin, G.A., and Karuntzos, G.T. The costs of an enhanced employee
assistance program (EAP) intervention. Evaluation and Program Planning 21(2):227236, 1998.
French, M.T., Dunlap, L.J., Zarkin, G.A., McGeary, K.A., and McLellan, A.T. A structured instrument for estimating the economic cost of drug abuse treatment. The Drug Abuse Treatment Cost
Analysis Program (DATCAP). Journal of Substance Abuse Treatment 14(5):445455, 1997.
French, M.T., Roebuck, M.C., McLellan, A.T., and Sindelar, J.L. Can the Treatment Services Review
be used to estimate the costs of addiction and ancillary services? Journal of Substance Abuse
12(4):341361, 2000.
French, M.T., McCollister, K.E., Sacks, S., McKendrick, K., and De Leon, G. Benefit-cost analysis of a
modified therapeutic community for mentally ill chemical abusers. Evaluation and Program Planning
25(2):137148, 2002.
French, M.T., Salome, H.J., and Carney, M. Using the DATCAP and ASI to estimate the costs and benefits of residential addiction treatment in the State of Washington. Social Science & Medicine
55(12):22672282, 2002.
Yates, B.T. Analyzing Costs, Procedures, Processes, and Outcomes in Human Services. Applied social
research methods series v. 42. Thousand Oaks, CA: Sage, 1996.
Yates, B.T. Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance Abuse
Treatment Programs: A Manual. NIH Publication No. 99-4518. Rockville, MD: National Institute on
Drug Abuse, 1999. http://www.nida.nih.gov/PDF/Costs.pdf.
Zarkin, G.A., and Dunlap, L.J. Implications of managed care for methadone treatment. Findings from
five case studies in New York State. Journal of Substance Abuse Treatment 17(1-2):2535, 1999.
Zarkin, G.A., Dunlap, L.J., and Homsi, G. The substance abuse services cost analysis program (SASCAP): A new method for estimating drug treatment services costs. Evaluation and Program Planning
27(1):3543, 2004.
160
Chapter 6
The Substance Abuse Services Cost Analysis

Program (Zarkin et al. 2004) is an emerging
treatment services cost estimation method.
Variants of these methods have been applied
to several treatment studies (Flynn et al.
2003; Koenig et al. 1999; Mojtabai and
Zivin 2003).
Three major categories of financial arrangements may be distinguished in managed care
contracts: (1) fee-for-service agreements, (2)
capitation agreements, and (3) case rate
agreements. Program administrators need to
understand the differences among these types
of arrangements so they can manage financial
risk. Sometimes, administrators may think
that the contract itself is the goal. However,
the existence of a contract is no guarantee of
a referral; it only enables referrals that are
medically necessary. The closer the relationship the program staff can develop with a
given MCO, the easier it will be for them to
understand their clinical criteria, to obtain
more than intermittent referrals, and to negotiate a financial arrangement for the program
that is reasonable and fair.
Managed care contracts vary according to two
principal dimensions: (1) the method of payment and the corresponding type of risk
assumed by the provider, and (2) the amount
of payment. Each of the three major types of
financial arrangements or methods of payment (described in Figure 6-1, p. 162) is associated with major financial risks that
providers should be aware of in negotiating
each type. Risk, of course, is a continuous
variable, so that no arrangement is devoid of
any risk whatsoever. The key is to ensure that
a program has the tools and capabilities to
manage the risks it assumes. Many managed
care systems rely on fee-for-service arrangements with providers, so that most providers
are paid on a discounted fee-for-service basis,
based on a schedule of fees described in the
contract. Capitation agreements usually are
reserved for very large networks of
providers, who in turn pay individual
providers on a fee-for-service basis.
For more information on managed care purchasing and negotiation from the perspective
of a purchaser, see TAP 22, Contracting for
Managed Substance Abuse and Mental Health
Services: A Guide for Public Purchasers
(CSAT 1998c).
Networks, Accreditation, and

Credentialing
To join an MCOs network of providers and
negotiate a contract specific MCO minimum
standards for staff credentials and program
accreditation must be met. These minimum
standards generally are not negotiable
because they have their basis in that MCOs
accreditation requirements. The provider
credentialing requirements vary by MCO and
by customer within the MCO and often
include primary verification of specific academic degrees or specific levels of licensure
for staff, as well as verified minimum levels of
malpractice insurance. Some MCOs may use
what are called independent Credentialing
Verification Organizations (CVOs) for this
process. These CVOs verify the credentials of
providers on behalf of MCOs to ensure, for
example, that their licenses are valid and up
to date.
MCOs sometimes are not familiar with substance abuse treatment and, moreover, typically include only those types of providers
that are licensed by a given State to engage in
private practice in their provider networks.
Usually such providers are licensed in psychology, nursing, medicine, or social work.
MCOs explain that this has to do with malpractice insurance issues. This credentialing
practice has a disproportionate impact on
those substance abuse treatment providers
that do not have as many staff with these credentials as do mental health providers, by
presenting an obstacle to contracting with
these MCOs. However, it is not an insurmountable obstacle. Substance abuse treatment providers often must help MCOs understand the substance abuse treatment environment, the types of providers that deliver ser161
Figure 6-1
Financial Arrangements for Providers
Method of Reimbursement
Cautions/Risks for Programs
Fee-for-Service Agreement. Fee-for-service programs are the least risky to providers. They generally require precertification and utilization
management for some or all procedures and services. The clients benefit plan document or the
public payors contract dictate the services that
may be approved. In a fee-for-service contract, a
rate is received for the services provided; typically, a standard program session with specific services bundled in. This is referred to as an allinclusive rate.
When negotiating a fee-for-service contract, an

administrator needs to ensure that the rate is sufficient to cover the actual costs to a program of
providing the specified services. During negotiations, the MCO has the option of saying that it will
not pay for some of the bundled services. All services should be costed out prior to negotiation, so
actual costs of treatment components are known
and can be compared to the reimbursement
offered. Programs must understand that even if a
fee-for-service contract is successfully negotiated,
referrals may or may not follow.
Some common bundled services are urine drug

screens and group, family, and individual counseling. Thus the payment rate for one visit may
include a 50-minute group counseling session and
a urine drug screen. The rate for a day of treatment could include, for example, one-fifth of a 25minute psychologist visit, one-half of a urine drug
screen, one-half of a vocational training session,
and two sessions of group counseling. The
assumption is that these services will occur at a
specified frequency during the course of the
clients treatment. Psychiatric services can be
incorporated into the bundled services, but usually they are negotiated separately and treated as an
additional service.
vices, and the qualifications and standards
they must meet so that the MCO can modify
its policies appropriately. MCOs often are
more willing to contract with organizations
that have a facility license from their State
than with individual substance abuse treatment providers who may not possess credentials that meet the MCOs licensure criteria.
Many managed care plans have separate
provider networks for behavioral health services. It is important for detoxification
providers to participate in both medical and
behavioral health networks, given that detoxi-
162
fication benefits may be considered either

medical or behavioral benefits.
In addition to the credentials of the staff and
practitioners, the program itself may have to
be accredited by one of the major national
healthcare accrediting organizations. These
include the Commission on Accreditation of
Rehabilitation Facilities (CARF;
www.carf.org), the National Committee for
Quality Assurance (NCQA;
www.ncqa.org/index.htm) and the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO; www.jcaho.org/). In
general, accreditation from CARF is considChapter 6
Figure 6-1 (continued)

Financial Arrangements for Providers
Method of Reimbursement
Cautions/Risks for Programs
Capitation Agreement. A managed care company

may establish a stipulated dollar amount to cover
treatment costs for a group of people using one
per-person rate for everyone, which is the MCOs
capitation rate. The MCO may then subcapitate a
stipulated dollar amount to a treatment provider
or organization, and the MCO and the treatment
provider negotiate an agreement in which the
provider is paid a fixed amount per subscriber
per month, rather than billing on a fee-for-service
basis. The provider agrees to provide all or some
of the treatment services for an expected number
of managed care covered lives (e.g., for 100,000
subscribers). Usually only large service providers
have the assets and volume of services to engage in
capitated agreements.
The two critical elements are the per member/per

month (pm/pm) rate and the utilization rate. If
many more people than are predicted require
treatment, the provider may not be able to cover
service delivery costs, much less make a profit/surplus. The key is to have reliable information on
the historical use rates of a given managed care
plans enrollees. If the provider bears in mind
these caveats, this regular, guaranteed payment
can be an excellent arrangement but carries with it
the risks of both overutilization (when compared to the assumption used in developing the
rate) and the need for a greater intensity of treatment than the capitation rate can cover. In some
cases a program may want to accept a somewhat
speculative capitation rate in order to join a panel
and then renegotiate that rate after the program
has collected data that show that it needs a higher
rate to cover its costs. In any case, it is crucial to
track actual dollars against the budget in real time
to avoid unexpected deficits.
Case Rate Agreement. The case rate is a fixed

rate per client paid for delivery of specific services to specified types of consumers. For this fee,
a provider such as a clinic covers all the services
that a client requires for a specific period. In
essence, the MCO is saying, You provide the
client what he needs from this set of services and I
will pay you this set amount. What usually distinguishes case rate from capitation is that essentially all of the case rate clients are anticipated to
be receiving some service; that is, at least case
management. Usually those receiving services
under capitation are a small minority of those
covered. The case rate may be risk-adjusted to
compensate for the higher costs of serving clients
who predictably need more services than average.
A case rate agreement removes some of the utilization risk from the service provider. However, the
risk remains that clients will need services more
frequently or at higher levels than the case rate
covers. It is essential that programs track costs by
specific client in order to assess the adequacy of a
proposed case rate. However, it is a mistake to
consider a case rate as a cap for any specific
patient; the goal is to ensure that the average cost
per case is lower than the negotiated case rate, not
that the cost for each case is less than the negotiated rate. Once again, it is crucial to track actual
average dollars per case against the contracted
case rate in real time to avoid unexpected deficits.
163
ered most important by substance abuse

treatment providers for their programs.
However, providers that wish to offer inpatient detoxification services generally must
obtain accreditation from JCAHO to meet the
requirements of most MCOs.
Organizational Performance
Measurement
Performance measurement is becoming an
increasingly important component of managed and fee-for-service care in both the public and private sectors. SAMHSAs SAPT
Block Grants now require the collection of
measures of program performance and outcomes. MCOs have their own performance
measures established by the agencies that
accredit them, such as the NCQA. Their customers, employers, or public purchasers may
use adequacy of performance on these measures in their decisions to acquire or retain
their plans for their employees. NCQA has
established a set of measures specifically
relating to substance abuse and mental health
treatment services for all the MCOs that it
accredits, including new measures of the identification of enrollees with substance abuse
diagnoses, the rate of initiation of treatment,
and a measure of treatment engagement.
Programs will be asked to participate in measuring these indicators and report that information to the MCO, and doing so will likely
be a condition of the contract. The MCO may
reward good performance with an additional
fee.
Similarly, MCOs evaluate the performance of
the members of their provider network. Each
MCO has its own measures and procedures
for implementation, some of which are prescribed by the organizations that accredit
them. Not all MCOs are diligent about this
provider evaluation process. Only a few
MCOs have implemented sophisticated measurement systems, and some of the methods
used today may be crude but they still are
required. Nevertheless, regardless of how
simple or complex they may be, the results of
164
external performance measures implemented

by MCOs can be extremely important to a
programs financial and organizational success, affecting a programs ability to remain a
viable, respected network provider. Some
performance management systems implemented by MCOs also use financial incentives
and/or disincentives keyed to performance.
Regardless of the specific measures implemented by particular MCOs, well-managed
organizations will also develop and use their
own internal performance measures and constantly strive to improve their own performance. Among these should be measures of
both process and outcomes, such as
The percentage of clients who complete a
defined treatment regimen that meets their
individual needs
The percentage of clients who drop out of
treatment in the first 7 days following treatment initiation
The percentage of clients who remain in documented but less intensive treatment 30 days
after discharge from the program
The percentage of clients who are employed
or attending school 6 months after discharge
from the program
When using performance measures, it is important for programs to account for differences
among clients that may affect measured results,
such as a clients previous history of abuse or
medical conditions. Nevertheless, it is equally
important to recognize that employing measurement is an integral component of external
and internal accountability as well as continuous clinical improvement.
One of the primary independent entities
involved in the construction of national performance measures for substance abuse treatment is the Washington Circle Group (WCG)
(see www.washingtoncircle.org). NCQAs new
substance abuse performance measures on
identification and initiation of treatment and
treatment engagement were developed by the
WCG over a 4-year period. They have identi-
Chapter 6
fied four major domains for substance

abuse treatment measures:
1. Prevention/Education
2. Recognition or Identification of Substance
Abuse
3. Treatment
Initiation of alcohol and other plan services
Linkage of detoxification and alcohol and
other drug plan services
Treatment engagement
Use of interventions for family members
and significant others
4. Maintenance of Treatment Effects
These and other substance abuse performance
measures are now used in NCQAs MCO
accreditation process. The WCG and others
have defined a variety of such measures and
administrators should think of these measures
as ways to improve their own performance, as
an essential element in the reporting system,
and as a means for documenting success to
their customers and other stakeholders.
Performance measurement is becoming
increasingly important outside of managed care
contracts as well as inside them. For example,
as mentioned in the previous section on funding, SAMHSA began integrating performance
measurement into the SAPT Block Grant as of
fiscal year 2004. Each State will expect programs to understand and be able to measure
the required indicators accurately and in a
timely way.
One of the most important performance measures in the future for detoxification programs
is likely to be linkages to substance abuse treatment following detoxification (Mark et al.
2002). Research has shown that patients who
receive continuing care following detoxification
have better outcomes in terms of drug abstinence and readmission rates than those who do
not receive continuing care. This focus on linkages is a likely result of research indicating that
many people who undergo detoxification do not
receive subsequent substance abuse services
from the formal treatment system and that the

lack of substance abuse treatment following
detoxification has been getting worse instead of
better (Mark et al. 2002). It is incumbent on
providers of detoxification services to ensure
that clients are linked to substance abuse treatment following detoxification.
Recordkeeping and management information systems

Like indemnity insurers, MCOs also require
detailed records of services provided to
clients in order for
them to pay for services received. The
programs accountPerformance
ing system needs to
track counselors
measurement is
time spent on the
phone, on paperbecoming an
work, and directly
with clients. Clinical
increasingly
records should
reflect accurately
important compothe claims records
submitted to the
nent of managed
MCO. Periodically,
payors and MCOs
and fee-for-service
may audit the clinical records to
ensure that the sercare in both the
vices billed for actually have been propublic and private
vided. Failure to
adequately docusectors.
ment clinical services can result in
nonpayment and
put a contract in jeopardy. On the other
hand, individuals private information and
identity must be handled in a confidential
manner pursuant to the Health Insurance
Portability and Accountability Act (HIPAA)
and Federal confidentiality requirements for
persons with substance abuse (for more information on HIPAA see
www.hipaa.samhsa.gov).
165
Managing multiple contracts requires sophisticated management, a fiscal management

information system (MIS), and constant
scrutiny. The need for information is even
more crucial for capitation-based arrangements that place risk on the service provider
than it is for fee-for-service arrangements. In
essence, the MIS needs to be capable of twoway information transfer between the MCO
and the program. Data such as membership,
benefits, copays, deductible amounts, and
other financial information must be passed
between the program and the
insured entity or
Successfully
payor. The MIS
also should be able
addressing the
to analyze key performance data for
needs of the
internal and external reports. The
utilization and
MIS must pass useful data to staff
case management
members responsible for managing
staff at MCOs is a
benefits and providing services.
critical element in
the relationship
with an MCO.
Program data will

need to meet State
data requirements
as well as requirements by each
payor, while
respecting confidentiality.
Managing payment from

multiple funding streams
Especially in the public arena, multiple contracts with and grants from several funding
streams and payors may be used to support
services for a single client. These contracts
will specify order of payment. The provider
needs to manage the funds carefully and
appropriately to be in compliance with contracts and grants. For example, a contract
with a drug court may specify that Medicaid
166
should be billed as payor number one and the

drug court as payor number two. Any unpaid
portion might then be billed to the block
grant agency as payor of last resort, if it is an
eligible service under the block grant. Some
providers have successfully used the strategy
of first using the reimbursement of those payors with the most restrictive array of services;
later, the more flexible funds can be used to
cover the remaining services. A clearly documented strategy for managing payment that is
communicated effectively to the accounts
payable staff is critical and will help programs be successful in this important area.
Utilization and Case

Management
All MCOs use methods to manage the service
utilization of their members and ensure that
they are receiving the most appropriate array
of services in the most appropriate environment or level of care for the appropriate
length of time. Although technically, utilization management focuses on a single type of
service and case management focuses on the
coordination of the appropriate array of services needed by a specific individual, in practice the same individual professionals may be
responsible for both types of management.
Utilization and case management staff at an
MCO authorize specific services for purposes
of payment. A wide variety of specific criteria
and protocols may be used to determine
whether services may be authorized for substance abuse, typically including the
American Society of Addiction Medicine
(ASAM) patient placement criteria (ASAM
2001) (see www.asam.org/ppc/ppc2.htm) and
other level of care or diagnosis-based criteria
sets.
Successfully addressing the needs of the utilization and case management staff at MCOs
responsible for authorizing care is a critical
element in the relationship with an MCO and
in maintaining the programs clinical and
financial viability. To do so, program staff
must understand what their counterparts do
Chapter 6
and be well trained in conducting professional

relationships over the telephone, be familiar
with the criteria and protocols employed by
the MCOs with which the program has contracts, and have easy access to the multitude
of clinical and service information required
by an MCO to help them complete a review
and authorize services. Excellent records are
essential. Program staff also should be familiar with each MCOs appeal or exceptions
process for those occasions when the outcome
of a first-level review is unsatisfactory.
Utilization management cannot proceed if the
program is not recognized as an eligible network provider; the program will have to
ensure that it is an accepted network
provider before it can participate in the utilization management or case management
process.
Strengthening the Financial

Base and Market Position of a
Program
The following strategies may strengthen the
market position of a detoxification program to
facilitate both larger numbers of patients and
greater revenues per patient:
Achieve recognition for the quality and
effectiveness of services. If a program has
a reputation for providing effective care,
then managed care enrollees and other
potential clients will want to use it. A program can be of value to a client, a purchaser, and/or an MCO if it can reduce repeated
detoxification, repeated treatment, and readmissions, and thus manage unnecessary
costs and interventions. Effective substance
abuse treatment provided promptly may
reduce medical care and hospitalization
costs in the long run. A program that effectively manages the care of high-utilization
substance abuse clients by also providing
psychiatric treatment, case management,
and housing support is a good candidate for
preferred or core status with one or
several MCOs or MBHOs. Of course, the
additional costs of these services need to be

a component of a programs rate and contract. Having highly reputable, recognized,
and efficient providers is a major marketing
and regulatory advantage for the health
plan, as well as for the program. All these
program characteristics can be marketing
advantages. Programs also may apply to
SAMHSAs National Registry of Evidencebased Programs and Practices, which recognizes model, effective, and promising programs. Check SAMHSAs Web site
(www.modelprograms.samhsa.gov) to find
out how to apply for this status, which is a
major achievement and marketing asset.
Serve specific populations. Providing lowcost, high-quality treatment to a population
no other program serves (e.g., adolescents,
clients with HIV/AIDS, clients with cooccurring mental disorders, pregnant
women, women with young children, clients
who are deaf) also is a possible marketing
advantage. Treating these clients can result
in client referrals from a larger geographic
area and multiple sources. Such clients may
bring with them higher reimbursement rates
too, but this also may simply reflect higher
costs to provide care to the population.
Using special capabilities to attract clients is
a good idea, but not at the cost of inadequate payment for services.
Develop economies of scale. Adding clinic
sites or increasing the number of branch
clinics may permit spreading some fixed
costs (e.g., management, information,
financial systems, executive staff) among a
larger number of patients, thus driving
down a programs per capita costs.
However, larger size requires greater
administrative coordination, which itself
can be costly.
Gain community visibility and support.
Having governmental, community agency
executives, or political figures (e.g., the
mayor, council members) as board members
raises the programs profile in the community. Of course, programs should be sure to
include board members who have specific
167
skills and connections that will advance the

purposes of the detoxification program.
Form alliances with other treatment
providers. Setting up coalitions to compete
with or work with MCOs and other purchasers such as Medicaid may be useful.
However, consultation with an attorney is
strongly advised prior to developing such a
coalition or other collaboration with local
treatment providers as the laws regarding
antitrust and other matters related to such
relationships are complex. For programs
serving publicly funded clients, technical
assistance may be available through CSAT;
the SSA can provide details.
Preparing for the

Future
Major forces that shape and limit provider
financing are unlikely to change substantially
in the near future. Careful strategic planning
168
and assurance of funding from reputable and

varied referral sources are essential for new
and existing programs. As a buffer against
shrinking budgets, all programs should consider broadening their funding streams and
referral sources, expanding the range of
clients they can serve, and promptly referring
clients for other services not provided on site.
Partnerships can be a critical factor to the
financial success of a program. To operate
effectively, administrators and other staff
must thoroughly understand the managed
care and community political environment
including its terminology, contracts, negotiations, payments, appeals, and priority populations. A successful working relationship
with an MCO, a health plan, other purchasers, or with another agency or group of
agencies depends on day-to-day interactions
in which staff members serve as informed,
professional advocates for their clients and
the program.
Chapter 6
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Appendix A
Appendix B: Common
Drug Intoxication
Signs and Withdrawal
Symptoms
Cocaine
Alcohol
Heroin
Cannabis
(marijuana)
Action
Stimulant
Sedative
Sedative, euphoriant, analgesic
Euphoriant, at
high doses may
induce hallucinations
Characteristics of
intoxication
BP, HR, temp,

energy,
paranoia,
fatigue,
appetite,
move bowels/
urinate
Sedation,
respiration,
Depresses CNS
system, can
result in coma,
death
Drowsiness, nodding, euphoria

(happy giddiness)
BP, HR,
intraocular pressure (pressure in
the eyes)
conjunctival injection (reddening of
the eyes)
Onset
Depends upon
type of cocaine
used: for crack
will begin within
hours of last use
2448 hours after

blood alcohol level
drops
Within 24 hours
of last use
Some debate
about this, may be
a few days
Duration
34 days
57 days
47 days
May last up to
several weeks
Intoxication
Withdrawal
223
Cocaine
Alcohol
Heroin
Cannabis
(marijuana)
Characteristics
Sleeplessness or
excessive restless
sleep, appetite
increase, depression, paranoia,
decreased energy
BP, HR,
temp,
nausea/vomiting/
diarrhea,
seizures, delirium,
death
Nausea, vomiting,
diarrhea, goose
bumps, runny
nose, teary eyes,
yawning
Irritability,
appetite disturbance, sleep disturbance, nausea,
concentration
problems, nystagmus, diarrhea
Medical/
psychiatric issues
Stroke, cardiovascular collapse,

myocardial and
other organ infarction, paranoia,
violence, severe
depression, suicide
Virtually every
organ system is
affected (e.g., cardiomyopathy, liver
disease, esophageal
and rectal
varices); fetal alcohol syndrome and
other problems
with fetus
During withdrawal
individual may
become dehydrated
224
Appendix B
Appendix C: Screening
and Assessment
Instruments
Please note that this list of screening and assessment instruments has
been divided into two sections. The first section comprises those instruments used for patients with suspected alcohol abuse or dependence
only; the second lists instruments used to screen and assess for abuse of
or dependence on any substances. Thus those tools that screen for all
substances of abuse are listed in section II.
Section I: Screening and

Assessment for Alcohol Abuse
This section of the appendix lists common screening and assessment
instruments specifically used in cases where abuse of or dependence
upon alcohol is in question.
The Alcohol Use Disorders Identification Test

(AUDIT)
Purpose: The purpose of the AUDIT is to identify persons whose alcohol consumption has become hazardous or harmful to their health.
Clinical utility: The AUDIT screening procedure is linked to a decision process that includes brief intervention with heavy drinkers or
referral to specialized treatment for patients who show evidence of
more serious alcohol involvement.
Groups with whom this instrument has been used: Adults, particularly primary care, emergency room, surgery, and psychiatric patients;
DWI offenders; offenders in court, jail, and prison; enlisted men in
the armed forces; workers receiving help from employee assistance
programs and in industrial settings.
225
Norms: Yes, heavy drinkers and people with

alcohol use disorders
Administrator training and qualifications: No

training required.
Format: A 10-item screening questionnaire

with 3 questions on the amount and frequency of drinking, 3 questions on alcohol dependence, and 4 on problems caused by alcohol.
Fee for use: No

Available from: Can be downloaded from
Project Cork Web site: http://www.projectcork.org/clinical_tools/index.html
Administration time: Two minutes

Scoring time: One minute
CAGE Questionnaire
Computer scoring? No
Purpose: Used to detect alcoholism.
Administrator training and qualifications:

The AUDIT is administered by a health professional or paraprofessional. Training is
required for administration. A detailed users
manual and a videotape training module
explain proper administration, procedures,
scoring, interpretation, and clinical management.
Clinical utility: The CAGE Questionnaire is a

very useful bedside, clinical desk instrument
and has become the favorite of many family
practice and general internists and among
nurses.
Groups with whom this instrument has been
used: Adults and adolescents (over 16 years
old)
Fee for use: No
Norms: Yes

Format: Very brief, relatively nonconfrontational questionnaire for detection of alcoholism, usually directed have you ever but
may be focused to delineate past or present
use.
Brief Michigan Alcoholism

Screening Test (BMAST)
Purpose: Used to screen for alcoholism with a
variety of populations.
Clinical utility: The BMAST can save clinicians time when integrated with instruments
used to screen for other behavioral health
problems (Pokorny et al. 1972).
used: Adults
Norms: N/A
Format: Ten-item questionnaire; interview or
paper-and-pencil
Administration time: Less than 1 minute

Scoring time: Instantaneous
training required for administration; it is
easy to learn, easy to remember, and easy to
replicate.
Fee for use: No
Administration time: Five minutes

Scoring time: Two to 3 minutes
226
Appendix C
Clinical Institute Withdrawal

Assessment (CIWA-Ar)
Purpose: Converts DSM-III-R items into
scores to track severity of withdrawal; measures severity of alcohol withdrawal.
Clinical utility: Aid to adjustment of care
related to withdrawal severity.
used: Adults
Norms: N/A
Format: Consists of 25 questions
Administration time: Ten minutes
Scoring time: Five minutes
training required.
Fee for use: Fee for a copy, no fee for use
Norms: N/A
Format: A 10-item scale for clinical quantification of the severity of the alcohol withdrawal syndrome.

Administration time: Two minutes
TWEAK
Scoring time: Four to 5 minutes
Purpose: Screens for heavy drinking and

alcohol dependence in the past year in male
and female samples of the general household
population and hospital clinic outpatients
(Chan et al. 1993).
Training is required; the CIWA-Ar can be
administered by nurses, doctors, research
associates, and detoxification unit workers.
Fee for use: No
Available from: Center for Substance Abuse
Treatment. A Guide to Substance Abuse
Services for Primary Care Clinicians.
Series 24. DHHS Publication No. (SMA) 973139. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 1997.
Clinical utility: The TWEAK provides a

quick and easy method of targeting outpatients and inpatients in need of more thorough assessments of their alcohol use patterns
and problems to determine whether treatment
is needed. The TWEAK has also been used to
screen for periconceptional risk drinking
among obstetric outpatients (Russell et al.
1994), which may improve pregnancy outcome among high-risk drinkers.
used: Adults
Michigan Alcoholism
Screening Test (MAST)
Norms: Yes
Purpose: Used to screen for alcoholism with a

variety of populations.
Format: Five items; pencil and paper selfadministered, administered by interview, or

computer self-administered.
Clinical utility: A 25-item questionnaire

designed to provide a rapid and effective
screen for lifetime alcohol-related problems
and alcoholism.
Administration time: Less than 2 minutes

Scoring time: Approximately 1 minute

used: Adults
Screening and Assessment Instruments
227

training required.
Fee for use: No
Section II: Screening

and Assessment for
Alcohol and Other
Drug Abuse
This section of the appendix lists common
screening and assessment instruments used in
cases where abuse of or dependence upon substances (including alcohol) is in question.
Addiction Severity Index (ASI)

Purpose: The ASI is most useful as a general
intake screening tool. It effectively assesses a
clients status in several areas, and the composite score measures how a clients need for
treatment changes over time.
Clinical utility: The ASI has been used extensively for treatment planning and outcome
evaluation. Outcome evaluation packages for
individual programs or for treatment systems
are available.
Fee for use: No cost; minimal charges for

photocopying and mailing may apply
Available from:
A. Thomas McLellan, Ph.D.
Building 7
PVAMC
University Avenue
Philadelphia, PA 19104
Phone: (800) 238-2433
Cocaine Selective Severity

Assessment (CSSA)
Purpose: Measures early cocaine abstinence
signs and symptoms.
Clinical utility: The CSSA is able to predict a
patients response to treatment and could be
used to identify patients at greater risk for
treatment failure so that these patients could
be targeted for additional interventions. This
instrument could also be used to evaluate the
effectiveness of medications intended to treat
cocaine abstinence symptoms.
used: Adults
Norms: N/A

used: Designed for adults of both sexes who
are not intoxicated (on illicit drugs or alcohol)
when interviewed. It is also available in
Spanish.
Format: Eighteen items
Norms: The ASI has been used with males

and females with substance use disorders in
both inpatient and outpatient settings.
Format: Structured interview

Administration time: Fifty minutes to 1 hour
Scoring time: Five minutes for severity rating
Computer scoring? Yes
228
Administrator training and qualifications: A

self-training packet is available as well as
onsite training by experienced trainers.
Administration time: Less than 10 minutes

Scoring time: N/A

Requires little training; clinician-administered
Available from: Kampman, K.M., Volpicelli,
J.R., McGinnis, D.E., Alterman, A.I.,
Weinrieb, R.M., DAngelo, L., and
Epperson, L.E. Reliability and validity of the
Appendix C
Cocaine Selective Severity Assessment.

Objective Opiate Withdrawal

Scale (OOWS)
Purpose: Used to record symptoms of opiate
withdrawal.
Clinical utility: Allows staff to share information about a clients withdrawal, especially
objective signs observed by staff.
Format: A psychiatric interview form in

which diagnosis can be made by the examiner
asking a series of approximately 10 questions
of a client.
Administration time: Administration of Axis I
and Axis II batteries may require more than 2
hours each for patients with multiple diagnoses. The Psychoactive Substance Use
Disorders module may be administered by
itself in 30 to 60 minutes.
Scoring time: Approximately 10 minutes

used: Adults
Computer scoring? No. Diagnosis can be

made by the examiner after the interview.
Norms: N/A

Designed for use by a trained clinical evaluator at the masters or doctoral level, although
in research settings it has been used by bachelors level technicians with extensive training.
Format: Thirteen manifestations of withdrawal; observer scores

Staff must be familiar with withdrawal signs
(e.g., registered nurse, physician) or trained.
Available from: Handelsman, L., Cochrane,
K.J., Aronson, M.J., Ness, R., Rubinstein,
K.J., and Kanof, P.D. Two new rating scales
for opiate withdrawal. American Journal of
Alcohol Abuse. 13:293308, 1987.
Fee for use: Yes

Available from:
American Psychiatric Publishing, Inc.
1400 K Street, N.W.
Washington, DC 20005
www.appi.org/
Structured Clinical Interview

for DSM-IV Disorders (SCID)
Stages of Change Readiness

and Treatment Eagerness
Scale (SOCRATES)
Purpose: Obtains Axis I and II diagnoses

using the DSM-IV diagnostic criteria for
enabling the interviewer to either rule out or
to establish a diagnosis of drug abuse or
drug dependence and/or alcohol abuse or
alcohol dependence.
Purpose: Designed to assess client motivation

to change drinking- or drug-related behavior.
Consists of five scales: precontemplation, contemplation, determination, action, and maintenance. Separate versions are available for
alcohol and illicit drug use.
Clinical utility: A psychiatric interview
Clinical utility: The SOCRATES can assist

clinicians with necessary information about
client motivation for change, an important
predictor of treatment compliance and outcome, and aid in treatment planning.

used: Psychiatric, medical, or communitybased normal adults.
Norms: No
Screening and Assessment Instruments

used: Adults
229
Norms: N/A
Format: Forty items; paper-and-pencil
Administration time: Five minutes
training required.
Fee for use: No
Treatment. Enhancing Motivation for Change
in Substance Abuse Treatment. Treatment
Rockville, MD: Substance Abuse and Mental
Health Services Administration, 1999.
Subjective Opiate Withdrawal

Scale (SOWS)
Purpose: Used to record clients impressions
or complaints of opiate withdrawal symptoms.
used: Adults
Norms: N/A
Format: Sixteen-item questionnaire; interview
or paper-and-pencil
Available from: Handelsman, L., Cochrane,
K.J., Aronson, M.J., Ness, R., Rubinstein,
K.J., and Kanof, P.D. Two new rating scales
for opiate withdrawal. American Journal of
Alcohol Abuse. 13:293308, 1987.
Clinical utility: Assessment of stages of

change/readiness construct can be used as a
predictor, and for treatment matching and
determining outcome variables.
used: Both inpatient and outpatient adults
Norms: Yes, for an outpatient alcoholism
treatment population
Format: The URICA is a 32-item inventory
designed to assess an individuals stage of
change located along a theorized continuum
of change.
Administration time: Five to 10 minutes to
complete
Scoring time: Four to 5 minutes
Computer scoring? Yes, using computer
scannable forms
N/A
Fee for use: Nothe instrument is in the
public domain
Treatment. Enhancing Motivation for Change
in Substance Abuse Treatment. Treatment
Rockville, MD: Substance Abuse and Mental
Health Services Administration, 1999.
University of Rhode Island

Change Assessment (URICA)
Purpose: The URICA operationally defines
four theoretical stages of change (precontemplation, contemplation, action, and maintenance), each assessed by eight items.
230
Appendix C
Appendix D:
Resource Panel
Brad Austin
Public Health Advisor
Division of State and Community Assistance PPG Program Branch
Rockville, Maryland
Christina Currier
Public Health Analyst
Practice Improvement Branch
Division of Services Improvement
Rockville, Maryland
Herman Diesenhaus
Public Health Analyst
Scientific Analysis Branch
Office of Evaluation, Scientific Analysis and Synthesis
Rockville, Maryland
Hendree E. Jones, M.A., Ph.D.
Assistant Professor
CAP Research Director
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University Center
Baltimore, Maryland
231
Robert Lubran, M.S., M.P.A.

Director
Division of Pharmacologic Therapies
Services Administration
Rockville, Maryland
Dennis Scurry, M.D.

Chief Medical Officer
Addiction of Prevention and Recovery
Administration
Government of the District of Columbia
Department of Health
Washington, DC
James J. Manlandro, D.O., FAOAAM,

FACOFP
Medical Director
Family Addiction Treatment Services, Inc.
Somers Point, New Jersey
Alan Trachtenberg, M.D., M.P.H.

Medical Officer
Division of Pharmacologic Therapies
Rockville, Maryland
Carol Rest-Mincberg
State Project Officer
Rockville, Maryland
232
Appendix D
Appendix E:
Field Reviewers
Karen C.O. Batia, M.A., Ph.D.
Senior Director
Mental Health and Addiction Services
Heartland Health Outreach
Chicago, Illinois
Thomas P. Beresford, M.D.
Professor
University of Colorado School of Medicine
Denver, Colorado
Barry Blood, LCPC
Addiction Counselor
Family Service Foundation
Columbia, Maryland
Patricia T. Bowman
Probation Counselor
Fairfax Alcohol Safety Action Program
Fairfax, Virginia
Barry S. Brown, M.S., Ph.D.
Adjunct Professor
University of North Carolina at Wilmington
Carolina Beach, North Carolina
Louis Cataldie, M.D.
Office for Addictive Disorders
Department of Health and Hospitals
Baton Rouge, Louisiana
233
David A. Chiriboga, Ph.D.

Professor
Department of Aging and Mental Health
Florida Mental Health Institute
University of South Florida
Tampa, Florida
Carol J. Colleran, CAP, ICADC
Director of Primary Programs
Center of Recovery for Older Adults
Hanley-Hazelden Center
West Palm Beach, Florida
Joy Davidoff
Coordinator of Addiction Medicine
New York State Office of Alcoholism and
Substance Abuse Services
Albany, New York
John P. de Miranda, Ed.M.
Executive Director
National Association on Alcohol, Drugs
and Disability, Inc.
San Mateo, California
B.J. Dean
Executive Director
Island Grove Regional Treatment Center,
Inc.
Greeley, Colorado
234
Robert Holden, M.A.

Program Director
Partners in Drug Abuse Rehabilitation
Counseling
Washington, DC
Kyle M. Kampman, M.D.
Associate Professor of Psychiatry
Medical Director
Treatment Research Center
University of Pennsylvania
Philadelphia, Pennsylvania
Michael Warren Kirby, Jr., M.A., Ph.D.
Chief Executive Officer
Thornton, Colorado
James J. Manlandro, D.O., FAOAAM,
FACOFP
Medical Director
Family Addiction Treatment Services, Inc.
Somers Point, New Jersey
Ethan Nebelkopf, Ph.D., MFCC
Director
Family and Child Guidance Clinic
Native American Health Center
Oakland, California
Ralph W. Edwards, M.P.H., M.P.A.

Director
Office of Citizen Leadership
Massachusetts Department of Mental
Health and Retardation
Boston, Massachusetts
Robert E. Olson, M.S.

Project Director
California Alcohol, Drug and Disability
Technical Assistance Project
National Association on Alcohol, Drugs
and Disability, Inc.
Belmont, California
Michael I. Fingerhood, M.D.

Associate Professor of Medicine
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Christopher Pond
Director of Adult Services
Thornton, Colorado
Michael M. Galer, D.B.A.

Chair
Graduate School of Business
University of Phoenix Greater Boston
Campus
Braintree, Massachusetts
Anthony B. Radcliffe, M.D.

Chief of Addiction Medicine
Fontana SCPMG
Kaiser Permanente/CDRP
Fontana, California
Appendix E
Jay Renaud
Member/Editor
J & M Reports
Guidepoints: Acupuncture in Recovery
Vancouver, Washington
Joseph P. Reoux, M.D.
Assistant Professor
Department of Psychiatry and Behavioral
Sciences
VA Puget Sound Health Care System
University of Washington School of
Medicine
Seattle, Washington
Timothy M. Scanlan, M.D.
Medical Director
Addiction Specialists of Kansas
Wichita, Kansas
Leslie R. Steve, M.A.

Native American Coordinator
Center for the Application of Substance
Abuse Technologies
University of Nevada
Reno, Nevada
Richard T. Suchinsky, M.D.
Associate Chief for Addictive Disorders and
Psychiatric Rehabilitation
Mental Health and Behavioral Sciences
Services
Department of Veterans Affairs
Washington, DC
Nancy R. VanDeMark, M.S.W.
Director
Research and Program Evaluation
Thornton, Colorado
Lawrence Schonfeld, Ph.D.

Professor
Louis de la Parte Florida Mental Health
Institute
Department of Aging and Mental Health
University of South Florida
Tampa, Florida
Melvin H. Wilson, M.B.A., LCSW-C

Baltimore HIDTA Coordinator
Maryland Department of Parole and
Probation
Clinton, Maryland
Steven Shevlin
Executive Director
Signs of Sobriety, Inc.
Ewing, New Jersey
Ann S. Yabusaki, M.Ed., M.A., Ph.D.

Substance Abuse Director
Psychologist
Substance Abuse Programs and Training
Coalition for a Drug-Free Hawaii
Kaneohe, Hawaii
Carla Shird, M.A., CSC-AD

Counselor
Mental Health Center
Gallaudet University Kellogg Conference
Center
Washington, DC
Mickey J.W. Smith, M.S.W.
Senior Policy Associate, Behavioral Health
Program, Policy & Practice Unit
Division of Professional Development &
Advocacy
National Association of Social Workers
Washington, DC
Field Reviewers
235
Index
Because the entire volume is about detoxification and substance abuse treatment, the use
of these terms as entry points has been minimized in this index. Commonly known
acronyms are listed as main headings. Page
references for information contained in figures appear in italics
A
acupuncture, 103104, 113
acute care inpatient settings, 1920
adolescents, 3031, 118
and club drugs, 97
Adult Detoxification levels of care, 13
adults, older, 109110
African Americans, 113115
aggressive behavior, 27
strategies for de-escalating, 28
alcohol withdrawal
and benzodiazepine treatment, 5861
contraindications to using benzodiazepines
during, 61
management with medication, 5758
management without medication, 55
medical complications, 54
and seizures, 6465
signs and symptoms, 5254
alternative treatment, 34, 103104
and disabilities, 113
American Indians, 116117
American Medical Association, position on
alcoholism, 3
Americans With Disabilities Act, 110
amphetamines. See stimulants
anabolic steroid withdrawal, 96
management, 97
medical complications of, 9697
patient care and comfort, 97
anticonvulsants, 62
antipsychotics, 62
anxiety disorders, 139141
antianxiety agents, 143
Asians and Pacific Islanders, 115116
assessment
and determining rehabilitation plans, 40
of psychosocial needs, 39
of severity of nicotine dependence, 8687
audience for this TIP, 2
Index
B
barbiturates, 6162
barriers to treatment
access, 4344
administrative, 39
benzodiazepine
contraindications, 61
limitations in outpatient treatment, 6061
and phenobarbital withdrawal equivalents, 77
and pregnant women, 106, 108
symptom-triggered therapy, 5859
tapering dosages, 59
and treatment of alcohol withdrawal, 5861
benzodiazepine withdrawal
biochemical markers, 48
biomedical evaluation domains, 25
bipolar disorders, 142143
blood alcohol content, 4849
breath alcohol levels, 50
buprenorphine
and opioid withdrawal, 7172
and pregnant women, 107
bupropion, 92
Byrne Formula Grant Program, 154
C
carve-outs, 157
case management, 44
case studies, 48, 102
CDT levels, 51
central nervous system depression, 66
childrens protective services, 154
Civilian Health and Medical Program of the
Veterans Administration, 152153
client advocates, 33
clinically managed residential detoxification, 17
Clinical Practice Guidelines for Detoxification of
Chemically Dependent Inmates, 119
clonidine
detoxification, 72
and rapid detoxification, 73
club drugs, 97
ecstasy, 99100
GHB, 9899
hallucinogens, 98
237
ketamine and PCP, 100101

cocaine. See stimulants
Commission on Accreditation of Rehabilitation
Facilities, 17, 27
Community Reinforcement and Family Training
(intervention), 34
complementary medicine. See alternative
treatment
confidentiality, 28, 165
confrontation, 35
Contracting for Managed Substance Abuse and
Mental Health Services: A Guide for
Public Purchasers, 161
contracts, managed care, 158159
co-occurring medical conditions, 2426, 26,
110113
acute trauma, 135
cancer, 134135
cardiovascular disorders, 125127
diabetes, 135
gastrointestinal disorders, 122125
general principles of care, 122
hematologic disorders, 127128
infectious disease, 132134
neurologic system effects, 129132
pulmonary disorders, 128129
co-occurring psychiatric conditions, 2728,
136137
anxiety disorders, 139141
bipolar disorders, 142143
depressive disorders, 141142
and pharmacologic agents, 137138
psychotic disorders, 143
and psychotropic medications, 138139
substance induced, 139
cost methodologies, 159161
criminal justice systems, 118119, 154
cultural competence, 3233, 44
questions to guide practitioners, 32
D
decisional balancing strategies, 37
definitions, 6
detoxification, 4
disabilities, 111
evaluation, 4
fostering entry to treatment, 5
maintenance, 6
regarding disabilities, 111
social detoxification, 17
stabilization, 4
substance, 5
substance intoxication, 5
238
substance-related disorder, 5
substance withdrawal, 5
treatment/rehabilitation, 56
delirium, 6366
delirium tremens, 63
depressive disorders, 27, 141142
antidepressants, 144
detoxification
building a program, 145146
clinically managed residential, 17
definition of, 4
as distinct from substance abuse treatment, 4
history of services, 23
inpatient versus outpatient programs, 20, 21
linkage with substance abuse treatment, 8
medical model of, 3
outpatient, 13
principles for care during, 24
rapid, ultrarapid, 73
service setting changes, 146
social model of, 3, 55
strengthening market position of program,
167168
disabilities, 110113, 112
definitions, 111
locating expert assistance, 114
domestic violence, 31
Drug Addiction Treatment Act of 2000, 72
drug-free environment, maintaining, 34
E
ecstasy, 99100
enhancing motivation, 34
ERs, and urgent care facilities, 15
evaluation
definition of, 4
initial, 24
F
Fetal Alcohol Syndrome, 108, 117
fostering entry to treatment, definition of, 5
freestanding substance abuse treatment
facility, 1617
funding issues, 147148, 155, 162163
grant funding, 156, 157
multiple funding streams, 166
G
gays and lesbians, 117118
GGT levels, 51
GHB, 9899
grant funding, 156, 157
guiding principles, 7
Index
H
hallucinogens, 98
hepatitis, and GGT levels, 51
Hispanics/Latinos, 117
history of detoxification services, 23
HIV/AIDS, 134
detoxification as a means to inhibit spread
of, 3
homeless patients, 43
I
incarcerated persons, 118119
Indian Health Service, 152
infectious disease, 2627, 132134
inhalant/solvent withdrawal
inhalants/solvents, commonly abused, 8384
inpatient detoxification programs, versus
outpatient programs, 20, 21
instruments, for dependence and withdrawal, 49
intensive outpatient programs, 1819
interventions
Community Reinforcement and Family
Training, 34
Johnson Intervention, 35
intoxication, signs and symptoms, 52, 53
J
Johnson Intervention, 35
Healthcare Organizations, 17, 27
K
ketamine, 100101
kindling effect, 54, 56
L
least restrictive care, 12
levels of care, 39
Adult Detoxification, 13
ambulatory detoxification, 14
clinically managed residential
detoxification, 17
medically monitored inpatient
detoxification, 17
urgent care facilities and ERs, 16
Index
linkages
to followup medical care, 45
to ongoing psychiatric services, 44
to treatment and maintenance activities, 42
M
malnutrition, 28
managed care
accreditation, 161162
contracts, 158159
financial risk in, 159161
performance measurement, 164165
recordkeeping, 165166
marijuana, 95
market position, strengthening, 167168
MCV levels, 51
Medicaid, 149150
medically monitored inpatient detoxification, 17
medical model of detoxification, 3
Medicare, 151
methadone
detoxification, 72
motivational enhancements, 34
N
nicotine, 8485
assessing severity of dependence, 8687
Fagerstrom Test for Nicotine Dependence, 87
Glover-Nilsson Smoking Behavioral
Questionnaire, 88
Treating Tobacco Use and Dependence:
Clinical Practice Guidelines, 90, 93
nicotine replacement therapy, 9192
combining, 9394
nicotine withdrawal, 86
effects of abstinence on blood levels of
psychiatric medications, 90
interventions, 9091, 91
signs and symptoms, 8586, 89
nutrition
deficits, 2930
evaluation, 2829
239
O
office-based detoxification. See detoxification,
outpatient
older adults, 109110
opioid withdrawal
and buprenorphine, 7172
and clonidine, 7071
and methadone, 6970
signs and symptoms, 6668, 67
outpatient programs, versus inpatient
programs, 20, 21
P
parents, 31
partial hospitalization programs. See intensive
outpatient programs
patient care and comfort, 66, 7374
anabolic steroid withdrawal, 97
inhalant/solvent withdrawal, 8384
nicotine withdrawal, 94
stimulant withdrawal, 81
patient education, 33
Patient Placement Criteria, ASAM, 1213, 39
performance measurement, 164165
pharmacotherapy
and anxiety disorders, 140141
and bipolar disorders, 142143
and depressive disorders, 141142
nonnicotine, 9293
phenobarbital withdrawal
and benzodiazepine, 77
and sedative-hypnotics, 78
physicians, and preparing patients to enter
detoxification, 13
placement matching, challenges to, 1112
polydrug abuse, 101102
prioritizing substances of abuse, 102103
pregnant women, 43, 105106
and alcohol, 106
and marijuana, 109
and nicotine, 108109
and opioids, 106108
and solvents, 108
and stimulants, 108
principles for care during detoxification, 24
Providers Introduction to Substance Abuse
Treatment for Lesbian, Gay, Bisexual,
and Transgender Individuals, A, 118
psychiatric services, linkages to, 44
psychosocial evaluation domains, 25
psychotic disorders, 143
240
public housing, 153

public intoxication, prior to 1970s, 23
R
rapid detoxification, 73
recordkeeping, 165166
referral sources, 146
Rehabilitation Act of 1973, 110
reimbursement systems, 8
relapse
chronic, 33
prevention, 6263
research funding, 156
rohypnol, 101
Ryan White CARE Act, 154
S
scope of this TIP, 2
sedative-hypnotics, and phenobarbital
withdrawal equivalents, 78
seizures, 6366
alcohol withdrawal, 6465, 130
what to do in the event of, 65
self-pay patients, 156
service costs, resources on, 160
service delivery, pitfalls of, 8
social detoxification, 3, 17, 5557
Social Security Disability Insurance, 151
social services, 153154
Social Services Block Grant, 153
solvents, and pregnant women, 108
stabilization, definition of, 4
staffing issues
inpatient detoxification programs, 18
in outpatient detoxification, 14
stages of change, 3537, 36
State Childrens Health Insurance Program, 152
steroids, anabolic, 96
stimulants, 76
stimulant withdrawal
medical complications of, 80, 81
symptoms, 7980
substance
changing patterns of use, 3
definition of, 5
dependence, chronic, 45
-induced psychiatric conditions, 139
Index
intoxication, definition of, 5

-related disorder, definition of, 5
withdrawal, definition of, 5
substance abuse epidemiology, 146147
Substance Abuse Prevention and Treatment
Block Grant, 149
substance abuse treatment
as distinct from detoxification, 4
funding issues, 147148, 155, 156, 157,
162163
linkage with detoxification, 8
suicide, 27
Supplemental Security Income, 151
support systems, 3334
symptom-triggered benzodiazepine therapy,
5859
T
tapering dosages, benzodiazepine, 59
Temporary Assistance to Needy Families, 153
THC abstinence syndrome, 95
therapeutic alliance, 3738
and clinician characteristics, 38
TIPs cited
Clinical Guidelines for the Use of
Buprenorphine in the Treatment of Opioid
Addiction (TIP 40), 71
Combining Alcohol and Other Drug Abuse
Treatment With Diversion for Juveniles in
the Justice System (TIP 21), 119, 154
Comprehensive Case Management for
Substance Abuse Treatment (TIP 27), 44, 45
Continuity of Offender Treatment for
Substance Use Disorders From Institution to
Community (TIP 30), 119, 154
Detoxification From Alcohol and Other Drugs
(TIP 19), 1
Enhancing Motivation for Change in Substance
Abuse Treatment (TIP 35), 34, 35
Improving Cultural Competence in Substance
Abuse Treatment (in development), 7, 44,
114, 116, 117
(TIP 43), 58, 69, 107
Role and Current Status of Patient Placement
Criteria in the Treatment of Substance
Use Disorders, The (TIP 13), 13, 41
Screening and Assessing Adolescents for
Substance Use Disorders (TIP 31), 31, 118
Screening for Infectious Diseases Among
Substance Abusers (TIP 6), 132
Index
Substance Abuse Among Older Adults (TIP 26),

110
Substance Abuse: Clinical Issues in Intensive
Outpatient Treatment (in development), 19
Substance Abuse Treatment: Addressing the
Specific Needs of Women (in development),
39, 106, 108, 109
Violence (TIP 25), 32
Substance Abuse Treatment for Adults in the
Criminal Justice System (TIP 44), 119, 154
Child Abuse and Neglect Issues (TIP 36), 44
Co-Occurring Disorders (TIP 42), 27, 45, 93,
112, 121, 137
HIV/AIDS (TIP 37), 134
Substance Abuse Treatment: Mens Issues (in
development), 39
Substance Use Disorder Treatment for People
With Physical and Cognitive Disabilities (TIP
29), 44, 110
Treatment of Adolescents With Substance Use
Disorders (TIP 32), 31, 118
Tuberculosis Epidemic: Legal and Ethical Issues
for Alcohol and Other Drug Abuse
Treatment Providers, The (TIP 18), 133
transtheoretical model. See stages of change
Treating Tobacco Use and Dependence: Clinical
Practice Guidelines, 90, 93
treatment
definition of, 56
initiation of, 42
settings, 41
TRICARE, 152
U
ultrarapid detoxification, 73
Uniform Alcoholism and Intoxication Treatment
Act, 3
urgent care facilities, and ERs, 15
urine drug screens, 50
utilization and case management, 166167
V
violence, 27
domestic, 31
vocational rehabilitation, 153154
241
W
Washington Circle Group, 4, 164
Web sites
American Cancer Society, 94
American Lung Association, 94
Byrne Formula Grant Program, 154
childrens protective services, 154
Civilian Health and Medical Program of the
Veterans Administration, 152153
Commission on Accreditation of
Rehabilitation Facilities, 17, 20, 21, 27, 162
grant funding sources, 157
Health Insurance Portability and
Accountability Act, 165
Indian Health Service, 152
Healthcare Organizations, 17, 20, 21, 27, 162
legal aspects of prescribing buprenorphine, 72
Medicaid, 150
Medicare, 151
model programs, 167
National Committee for Quality Assurance,
162
National Institute on Alcohol Abuse and
Alcoholism, 156
242
National Institute on Drug Abuse, 156

Patient Placement Criteria, ASAM, 166
public housing, 153
Research Assistant, The, 156
Ryan White CARE Act, 154
SAMHSA funding opportunities, 149
Social Security Disability Insurance, 151
State Childrens Health Insurance Program,152
Temporary Assistance to Needy Families, 153
TRICARE, 152
vocational rehabilitation, 154
Washington Circle Group, 164
withdrawal, 2426, 33. See also alcohol withdrawal; anabolic steroid withdrawal; benzodiazepine withdrawal; inhalant/solvent withdrawal; nicotine withdrawal; opioid withdrawal;
stimulant withdrawal
women, pregnant, 43, 105106
wraparound services, 43
Z
Zyban, 92
Index
CSAT TIPs and Publications Based on TIPs

What Is a TIP?
Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians,
researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under CSATs Knowledge Application Program to improve the treatment capabilities of the
Nations alcohol and drug abuse treatment service system.
What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is
divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so providers can refer back to the source document for more information.
What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept within a
treatment providers reach and consulted frequently. The Keys allow youthe busy clinician or program administratorto locate
information easily and to use this information to enhance treatment services.
TIP 1
State Methadone Treatment GuidelinesReplaced by

TIP 43
TIP 12 Combining Substance Abuse Treatment With

Intermediate Sanctions for Adults in the Criminal
Justice SystemReplaced by TIP 44
TIP 2* Pregnant, Substance-Using Women BKD107

Quick Guide for Clinicians QGCT02
KAP Keys for Clinicians KAPT02
TIP 3
TIP 4
TIP 5
TIP 6
Screening and Assessment of Alcohol- and Other

Drug-Abusing AdolescentsReplaced by TIP 31
Guidelines for the Treatment of Alcohol- and Other
Drug-Abusing AdolescentsReplaced by TIP 32
Improving Treatment for Drug-Exposed Infants
BKD110
Screening for Infectious Diseases Among Substance
AbusersBKD131
TIP 7
Screening and Assessment for Alcohol and Other

Drug Abuse Among Adults in the Criminal Justice
SystemReplaced by TIP 44
TIP 8* Intensive Outpatient Treatment for Alcohol and Other

Drug AbuseBKD139
TIP 9
Assessment and Treatment of Patients With Coexisting

Mental Illness and Alcohol and Other Drug Abuse
Replaced by TIP 42
TIP 13 Role and Current Status of Patient Placement

Criteria in the Treatment of Substance Use
DisordersBKD161
Quick Guide for Administrators QGAT13
TIP 14 Developing State Outcomes Monitoring Systems for
Alcohol and Other Drug Abuse TreatmentBKD162
TIP 15 Treatment for HIV-Infected Alcohol and Other Drug
AbusersReplaced by TIP 37
TIP 16 Alcohol and Other Drug Screening of Hospitalized
Trauma PatientsBKD164
TIP 17 Planning for Alcohol and Other Drug Abuse
Treatment for Adults in the Criminal Justice System
Replaced by TIP 44
TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues
for Alcohol and Other Drug Abuse Treatment
ProvidersBKD173
TIP 10 Assessment and Treatment of Cocaine-Abusing

Methadone-Maintained PatientsReplaced by TIP 43
TIP 19 Detoxification From Alcohol and Other Drugs

Replaced by TIP 45
TIP 11 Simple Screening Instruments for Outreach for

Alcohol and Other Drug Abuse and Infectious
Diseases BKD143
TIP 20 Matching Treatment to Patient Needs in Opioid

Substitution TherapyReplaced by TIP 43

*Under revision
243
TIP 21 Combining Alcohol and Other Drug Abuse Treatment

With Diversion for Juveniles in the Justice System
BKD169
Quick Guide for Clinicians and Administrators
QGCA21
TIP 22 LAAM in the Treatment of Opiate Addiction
Replaced by TIP 43
TIP 23 Treatment Drug Courts: Integrating Substance Abuse
Treatment With Legal Case ProcessingBKD205
TIP 29 Substance Use Disorder Treatment for People With

Physical and Cognitive DisabilitiesBKD288
TIP 30 Continuity of Offender Treatment for Substance Use
Disorders From Institution to CommunityBKD304

TIP 24 A Guide to Substance Abuse Services for Primary
Care CliniciansBKD234
Concise Desk Reference Guide BKD123
TIP 25 Substance Abuse Treatment and Domestic Violence
BKD239
Linking Substance Abuse Treatment and
Domestic Violence Services: A Guide for Treatment
Providers MS668
Linking Substance Abuse Treatment and Domestic
Violence Services: A Guide for Administrators MS667
TIP 26 Substance Abuse Among Older Adults BKD250
Substance Abuse Among Older Adults: A Guide
for Treatment Providers MS669
Substance Abuse Among Older Adults: A Guide
for Social Service Providers MS670
Substance Abuse Among Older Adults:
Physicians Guide MS671
TIP 27 Comprehensive Case Management for Substance
Abuse TreatmentBKD251
Case Management for Substance Abuse Treatment: A
Guide for Treatment Providers MS673
Case Management for Substance Abuse Treatment: A
Guide for Administrators MS672
TIP 28 Naltrexone and Alcoholism TreatmentBKD268
Naltrexone and Alcoholism Treatment: Physicians
Guide MS674
TIP 31 Screening and Assessing Adolescents for Substance

Use DisordersBKD306
See companion products for TIP 32.
TIP 32 Treatment of Adolescents With Substance Use
DisordersBKD307
Quick Guide for Clinicians QGC312
KAP Keys for Clinicians KAP312
TIP 33 Treatment for Stimulant Use DisordersBKD289
TIP 34 Brief Interventions and Brief Therapies for Substance
AbuseBKD341
TIP 35 Enhancing Motivation for Change in Substance Abuse
TreatmentBKD342
TIP 36 Substance Abuse Treatment for Persons With Child
Abuse and Neglect IssuesBKD343
Helping Yourself Heal: A Recovering Womans Guide
to Coping With Childhood Abuse IssuesPHD981
Available in Spanish: PHD981S

Helping Yourself Heal: A Recovering Mans Guide to
Coping With the Effects of Childhood AbuseHD1059
Available in Spanish: PHD1059S

TIP 37 Substance Abuse Treatment for Persons With
HIV/AIDSBKD359
Fact Sheet MS676
Quick Guide for Clinicians MS678

244
*Under revision
TIP 38 Integrating Substance Abuse Treatment and

Vocational ServicesBKD381
TIP 43 Medication-Assisted Treatment for Opioid Addiction

in Opioid Treatment ProgramsBKD524

TIP 39 Substance Abuse Treatment and Family Therapy
BKD504
TIP 40 Clinical Guidelines for the Use of Buprenorphine in
the Treatment of Opioid AddictionBKD500
TIP 44 Substance Abuse Treatment for Adults in the Criminal

Justice SystemBKD526
TIP 45 Detoxification and Substance Abuse Treatment
BKD541
Quick Guide for Physicians QGPT40
KAP Keys for Physicians KAPT40
TIP 41 Substance Abuse Treatment: Group Therapy

BKD507
TIP 42 Substance Abuse Treatment for Persons With CoOccurring DisordersBKD515
245
Treatment Improvement Protocols (TIPs) from the Substance Abuse and Mental Health Services
Administrations (SAMHSAs) Center for Substance Abuse Treatment (CSAT)
Place the quantity (up to 5) next to the publications you would like to receive and print your mailing address below.
___TIP 2* BKD107
___QG+ for Clinicians QGCT02
___KK+ for Clinicians KAPT02
___TIP 5 BKD110
___TIP 6 BKD131
___QG for Clinicians QGCT06
___KK for Clinicians KAPT06
___TIP 8* BKD139
___TIP 11 BKD143
___TIP 13 BKD161
___QG for Administrators QGAT13
___TIP 14 BKD162
___TIP 16 BKD164
___TIP 26 BKD250
___Guide for Treatment Providers MS669
___Guide for Social Service Providers
MS670
___Physicians Guide MS671
___TIP 27 BKD251
___Guide for Administrators MS672
___TIP 28 BKD268
___Physicians Guide MS674
___TIP 29 BKD288
___TIP 30 BKD304
___TIP 18 BKD173
___TIP 31 BKD306
(see products under TIP 32)
___TIP 21 BKD169
___QG for Clinicians & Administrators
QGCA21
___TIP 32 BKD307
___QG for Clinicians QGC312
___KK for Clinicians KAP312
___TIP 23 BKD205
___TIP 33 BKD289
___TIP 24 BKD234
___Desk Reference BKD123
___TIP 25 BKD239
___Guide for Administrators MS667
___TIP 34 BKD341
___TIP 35 BKD342
___TIP 36 BKD343
___Brochure for Women (English)
PHD981
___Brochure for Women (Spanish)
PHD981S
___Brochure for Men (English)
PHD1059
___Brochure for Men (Spanish)
PHD1059S
___TIP 37 BKD359
___Fact Sheet MS676
___QG for Clinicians MS678
___TIP 38 BKD381
___TIP 39 BKD504
___TIP 40 BKD500
___QG for Physicians QGPT40
___KK for Physicians KAPT40
___TIP 41 BKD507
___TIP 42 BKD515
___TIP 43 BKD524
___KK for Physicians KAPT43
___TIP 44 BKD526
___TIP 45 BKD541
*Under revision
+QG = Quick Guide; KK = KAP Keys
Name:
Address:
City, State, Zip:
Phone and e-mail:
You can either mail this form or fax it to (301) 468-6433. Publications also can be ordered by calling SAMHSAs NCADI at
(800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
TIPs can also be accessed online at www.kap.samhsa.gov.
FOLD
STAMP
SAMHSAs National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345
Rockville, MD 20847-2345
FOLD
Detoxification and
This TIP is a revision of TIP 19, Detoxification From Alcohol and

Other Drugs, and was created by a panel of experts with diverse
experience in detoxification servicesphysicians, psychologists,
counselors, nurses, and social workers. This revision provides upto-date information about changes in the role of detoxification
in the continuum of services for patients with substance use disorders, increased knowledge of the physiology of withdrawal,
pharmacological advances in the management of withdrawal,
patient placement procedures, and new issues in the management of detoxification services within comprehensive systems of
care. It also expands on the administrative, legal, and ethical
issues commonly encountered in the delivery of detoxification
services and suggests performance measures for detoxification
programs.
Collateral Products
Based on TIP 45
Quick Guide for Clinicians
KAP Keys for Clinicians

Printed 2006

DETOXIFICATION
Detoxification and Substance Abuse Treatment
TIP 45

Detoxification and Substance Abuse Treatment TIP 45 U.S.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

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Public Domain Notice

All materials appearing in this volume except

Electronic Access and Copies

Chapter 5Co-Occurring Medical and Psychiatric Conditions.......................................121

A large and diverse group of experts closely

Workgroup Managers and

Anthony Radcliffe, M.D., FASAM

Charles A. Dackis, M.D.

Hendree E. Jones, M.A., Ph.D.

KAP Expert Panel and Federal

Michael Galer, D.B.A., M.B.A., M.F.A.

Carlo C. DiClemente, Ph.D.

Mary Beth Johnson, M.S.W.

Catherine E. Dube, Ed.D.

Eduardo Lopez, B.S.

Jerry P. Flanzer, D.S.W., LCSW, CAC

Holly A. Massett, Ph.D.

Nedra Klein Weinreich, M.S.

5. Level IV-D: Medically Managed Intensive

Matching patients to appropriate care represents a challenge to detoxification programs.

1. Level I-D: Ambulatory Detoxification

ASAM criteria are being adopted extensively

access to treatment for individuals seeking

medication or the psychiatric condition was

The setting in which detoxification occurs is

unusual in a clinical treatment improvement

the MCO may use a wide variety of specific

with each MCOs appeal or exceptions process

Purpose of the TIP

Purpose of the TIP

This TIP provides clinicians with up-to-date

provide detoxification servicesto be prepared to participate in the process of getting

1995; Sadd and Young 1987). Shifts in the

Overview, Essential Concepts, and Definitions in Detoxification

tems all define detoxification differently. This

taken special care to note that detoxification

Detoxification as Distinct From Substance

other significant people when appropriate

Other Relevant Terms

stance-induced disorders. According to the

Treatment/rehabilitation includes an ongoing,

Overview, Essential Concepts, and Definitions in Detoxification

A drug of abuse, a medication, or a toxin.

Disorders related to the taking of a drug of abuse (including

Substance abuse (in this TIP, also

Substance dependence (in this TIP,

A cluster of cognitive, behavioral, and physiological symptoms

The development of a reversible substance-specific syndrome as

The development of a substance-specific maladaptive behavioral

Source: APA 2000.

Maintenance includes the continuation of

patients to emphasize that these persons are

As a final note, in this TIP persons in need of

empirically measurable and agreed upon by all

Finally the average length of stay for people

insurers try to reach agreements on the level

Overview, Essential Concepts, and Definitions in Detoxification

Role of Various Settings in the

Least Restrictive Care

2. Biomedical Conditions and Complications